1
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Nadeem A, Salei A. Percutaneous biliary stent removal for benign biliary stricture post hepaticojejunostomy. BMJ Case Rep 2024; 17:e259589. [PMID: 38599795 PMCID: PMC11015180 DOI: 10.1136/bcr-2023-259589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/12/2024] Open
Abstract
This case report presents the percutaneous extraction of a biliary stent in a patient with a history of liver transplant and Whipple procedure, suffering from benign biliary stricture post hepaticojejunostomy. After failed management with conventional benign biliary protocol, a fully covered WallFlex biliary stent was percutaneously placed and later removed using a balloon catheter technique. The procedure demonstrated anastomosis patency without complications, providing a drain-free option for complex anatomy where endoscopic management was not feasible. This case contributes valuable insights to the limited literature on percutaneous stent removal for benign biliary strictures, emphasising the importance of considering alternative approaches in challenging clinical scenarios.
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Affiliation(s)
- Arsalan Nadeem
- Department of Medicine, Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | - Aliaksei Salei
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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2
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Buchheit JT, Joshi I, Dixon ME, Peng JS. Total pancreatectomy, splenectomy and remnant gastrectomy for invasive intraductal papillary mucinous neoplasm (IPMN) after prior Roux-en-Y gastric bypass. BMJ Case Rep 2024; 17:e258071. [PMID: 38594195 PMCID: PMC11015188 DOI: 10.1136/bcr-2023-258071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
A female patient in her 50s presented with abdominal pain, nausea and jaundice. She had a history of prior Roux-en-Y gastric bypass and her body mass index was 52.5 kg/m2 Biochemical testing revealed a total bilirubin level of 14.3 mg/dL (normal<1.2 mg/dL) and carbohydrate antigen 19-9 of 38.3 units/mL (normal<36.0 units/mL). CT demonstrated a 3.2 cm pancreatic head mass, biliary and pancreatic duct dilation and cystic replacement of the pancreas. The findings were consistent with a diagnosis of mixed-type intraductal papillary mucinous neoplasm (IPMN) with invasive malignancy. The patient's Roux-en-Y anatomy precluded endoscopic biopsy, and she underwent upfront resection with diagnostic laparoscopy, open total pancreatectomy, splenectomy and remnant gastrectomy with reconstruction. Pathology confirmed T2N1 pancreatic adenocarcinoma, 1/29 lymph nodes positive and diffuse IPMN. She completed adjuvant chemotherapy. IPMNs have malignant potential and upfront surgical resection should be considered without biopsy in the appropriate clinical setting.
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Affiliation(s)
| | - Isha Joshi
- Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Matthew E Dixon
- Division of Surgical Oncology, Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - June S Peng
- Division of Surgical Oncology, Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
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3
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Abdalla M, Abdalla S, Panda N, Castillo CFD. Haemosuccus pancreaticus and seven episodes of recurrent unlocalised upper gastrointestinal bleeding. BMJ Case Rep 2024; 17:e256960. [PMID: 38383120 PMCID: PMC10882450 DOI: 10.1136/bcr-2023-256960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
Upper gastrointestinal (GI) bleeding is a common medical condition that results in extensive morbidity and mortality, as well as substantial healthcare costs. While there is variation among society and consensus guidelines, the approaches to assessment and evaluation are generally consistent. Our case describes a man in his 40s who presented with seven episodes of recurrent upper GI bleeding over 2 years secondary to haemosuccus pancreaticus. While rare, this case study highlights key principles to the initial diagnostic approach that, in appropriate clinical contexts, should be applied to patients with unlocalised upper GI bleeding. We further perform a complete systematic review of similar cases available in PubMed (36 patients in 24 case reports) to further refine these diagnostic principles.
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Affiliation(s)
- Moustafa Abdalla
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Salwa Abdalla
- Department of Computer Science, University of Toronto, Toronto, Toronto, Canada
| | - Nikhil Panda
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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4
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Moreno S, Ksontini R. Intrahepatic biloma after intraoperative cholangiography. BMJ Case Rep 2024; 17:e257688. [PMID: 38182172 PMCID: PMC10773284 DOI: 10.1136/bcr-2023-257688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
A woman in her 30s presented to the emergency department with a month-long history of postprandial epigastric pain radiating to her back. The diagnosis of cholecystolithiasis and suspected choledocholithiasis was made, and the patient underwent cholecystectomy with cholangiography using standard technique. The surgery was complicated by an intrahepatic bile duct injury attributed to high injection pressure during cholangiography. She developed an intrahepatic collection that was drained and confirmed the diagnosis of biloma. In this case report, we discuss a rare complication of intraoperative cholangiography during laparoscopic cholecystectomy and consider a way to prevent it.
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Affiliation(s)
- Samara Moreno
- Soins intensifs, Hôpital Riviera-Chablais, Rennaz, Switzerland
| | - Riadh Ksontini
- Soins intensifs, Hôpital Riviera-Chablais, Rennaz, Switzerland
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5
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Cohen EM, Russeth TE, Thati N. Hypereosinophilia as a presenting sign of advanced pancreatic adenocarcinoma: a rare, severe presentation. BMJ Case Rep 2023; 16:e256235. [PMID: 38151269 PMCID: PMC10753747 DOI: 10.1136/bcr-2023-256235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2023] [Indexed: 12/29/2023] Open
Abstract
Pancreatic adenocarcinoma (PA) is the third most lethal malignancy worldwide with only a 7.7% 5-year survival rate. Prognosis is poor with more than 50% of patients presenting with stage IV disease. Despite focused attention on early detection and treatment, pathogenesis and early symptomatology are not well described. In addition to prodromal symptoms, hypereosinophilia has been identified as a marker of malignancy in both PA and other solid tumour and haematological malignancies. Peripheral hypereosinophilia (PH) secondary to solid organ tumours, however, is rare, with only four cases of PA reported to date. We present a case of advanced PA with associated severe PH in a man in his early 50s. Time from diagnosis to death in this patient was only 6 weeks, emphasising the need to consider malignancy in the differential diagnosis for a patient that presents with a severe PH of unknown origin.
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Affiliation(s)
- Ethan M Cohen
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Tyler E Russeth
- Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Neelima Thati
- Internal Medicine, Detroit Medical Center, Detroit, Michigan, USA
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6
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Aggarwal S, Nandi S, Verma A, Kumar N. Peripancreatic tuberculosis. BMJ Case Rep 2023; 16:e256433. [PMID: 38086575 PMCID: PMC10728911 DOI: 10.1136/bcr-2023-256433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Peripancreatic tuberculosis (PTB) is a very rare variant of tuberculosis and its clinical and radiological findings are similar to those of pancreatic malignancy. Diagnosis of PTB is usually incidental and is made after surgical resection. We are presenting a male patient who had complaints of prolonged fever, significant weight loss and yellowish discolouration of eyes and dark-coloured urine. Investigations revealed that there was a pancreatic mass causing obstructive jaundice. However, the aetiology of the mass, whether tubercular or malignant, was not clear. Hence, the patient was planned for endoscopic ultrasound-guided fine needle aspiration cytology. Cytology and aspirate were sent for a cartridge-based nucleic acid amplification test which revealed the presence of Mycobacterium tuberculosis, sensitive to rifampicin. The patient improved completely after treatment with antitubercular therapy.
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Affiliation(s)
- Sunita Aggarwal
- General Medicine, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Sudipta Nandi
- General Medicine, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Abhishek Verma
- General Medicine, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Naresh Kumar
- General Medicine, Maulana Azad Medical College, New Delhi, Delhi, India
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7
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Baskaran S, Lodha M, Kumar RR, Elhence P. Spontaneous rupture of solid pseudopapillary epithelial neoplasm of pancreas with intraperitoneal haemorrhage. BMJ Case Rep 2023; 16:e257398. [PMID: 38081741 PMCID: PMC10728932 DOI: 10.1136/bcr-2023-257398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Affiliation(s)
- Suruthi Baskaran
- General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mahendra Lodha
- General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ravi Ranjan Kumar
- General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Poonam Elhence
- Pathology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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8
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Andersen LM, Goh IY, Siriwardhane M. High-grade dysplasia of the cystic duct margin: how should this be managed? BMJ Case Rep 2023; 16:e255492. [PMID: 38081746 PMCID: PMC10729155 DOI: 10.1136/bcr-2023-255492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
High-grade dysplasia (HGD) in the cystic duct is a rare epithelial lesion that may lead to biliary tract malignancy. Due to its association with aggressive multifocal cholangiocarcinoma, it is important to investigate for concurrent malignancy, remove all areas of HGD and monitor for recurrence or metastasis.We present a case of a woman in her 60s with cholecystitis who underwent a laparoscopic cholecystectomy. On histopathology, the patient was found to have incidental HGD involving the cystic duct margin. After ensuring the absence of concurrent malignancy on cross-sectional imaging, she underwent further resection until the margins were clear of dysplasia. In the absence of clear follow-up guidelines, the patient was closely monitored with outpatient scans for up to 5 years.
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Affiliation(s)
- Lalita Maria Andersen
- General Surgery, Mater Adult Hospital, South Brisbane, Queensland, Australia
- General Surgery, GCUH, Southport, Queensland, Australia
| | - Ian Y Goh
- Surgery, Hervey Bay Hospital, Pialba, Queensland, Australia
| | - Mehan Siriwardhane
- General Surgery, Mater Adult Hospital, South Brisbane, Queensland, Australia
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9
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Nagao M, Ueo T, Fukuda A, Ohana M. Intraductal papillary mucinous carcinoma with co-mutations of KRAS/STK11. BMJ Case Rep 2023; 16:e255945. [PMID: 38011945 PMCID: PMC10685908 DOI: 10.1136/bcr-2023-255945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Affiliation(s)
- Munemasa Nagao
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, kyoto, Japan
- Department of Gastroenterology and Hepatology, Tenri Hospital, Tenri, Nara, Japan
| | - Taro Ueo
- Department of Gastroenterology and Hepatology, Tenri Hospital, Tenri, Nara, Japan
| | - Akihisa Fukuda
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, kyoto, Japan
| | - Masaya Ohana
- Department of Gastroenterology and Hepatology, Tenri Hospital, Tenri, Nara, Japan
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10
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Maclean E, Delriviere L, Johansson M, Hodder R. Resection of previously inoperable retroperitoneal liposarcoma. BMJ Case Rep 2023; 16:e256479. [PMID: 37945281 PMCID: PMC10649782 DOI: 10.1136/bcr-2023-256479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
We present a case of successful resection of a large right upper quadrant retroperitoneal dedifferentiated liposarcoma involving multiple adjacent organs, initially considered inoperable in a patient in his 40s. This case highlights the importance of extensive preoperative planning and a multidisciplinary approach in achieving a greater chance of curative resection. Preoperative optimisation included neoadjuvant chemotherapy, concurrent portal vein embolisation and hepatic vein embolisation. The patient then underwent en-bloc resection, including total pancreatectomy, hemihepatectomy and vena caval resection in conjunction with extracorporeal membrane oxygenation and percutaneous venovenous bypass.
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Affiliation(s)
- Ellen Maclean
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Luc Delriviere
- Department of Surgical Transplant, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Mikael Johansson
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Rupert Hodder
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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11
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Chan R, Stueck A, Stewart M, Kohansal A. Sarcomatoid carcinoma of the common bile duct presenting as painless jaundice. BMJ Case Rep 2023; 16:e257167. [PMID: 37945274 PMCID: PMC10649720 DOI: 10.1136/bcr-2023-257167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
A woman in her 70s presented with painless jaundice and index biopsy of a common bile duct (CBD) mass obtained by endoscopic retrograde cholangiopancreatography was suspicious for malignant peripheral nerve sheath tumour. Treatment consisted of pancreaticoduodenectomy, and final pathology results were consistent with sarcomatoid carcinoma. Postoperative complications included pancreaticojejunal leak, surgical wound infection, bacteraemia, myocardial injury, and significant ulceration and stricturing of the oesophagus. 14 weeks post-pancreaticoduodenectomy, the patient was found to have a perforated viscus, gastroduodenal leak and diffuse small bowel ischaemia-the patient passed away following emergent laparotomy. We aim to add to the limited literature surrounding this rare CBD neoplasm.
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Affiliation(s)
- Rachael Chan
- Gastroenterology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ashley Stueck
- Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Stewart
- Gastroenterology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ali Kohansal
- Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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12
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Kwong E, Sanders D, Kwong S. Diffuse myelomatous infiltration of the pancreas. BMJ Case Rep 2023; 16:e256250. [PMID: 37931959 PMCID: PMC10632812 DOI: 10.1136/bcr-2023-256250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Affiliation(s)
- Evan Kwong
- Faculty of Medicine, University of British Columbia, Kelowna, British Columbia, Canada
| | - David Sanders
- Gastroenteroloy, Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - Stephen Kwong
- Medical Imaging, Kelowna General Hospital, Kelowna, British Columbia, Canada
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13
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Neubeck KM, Mwagiru D, Boseto EF. Acute cholecystitis following elective colonoscopy. BMJ Case Rep 2023; 16:e257166. [PMID: 37918945 PMCID: PMC10626896 DOI: 10.1136/bcr-2023-257166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023] Open
Affiliation(s)
- Kimberley Maree Neubeck
- General Surgery, Bathurst Base Hospital, Bathurst, New South Wales, Australia
- General Surgery, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Derek Mwagiru
- General Surgery, Bathurst Base Hospital, Bathurst, New South Wales, Australia
- General Surgery, Westmead Hospital, Westmead, New South Wales, Australia
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14
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Thapa S, Allakky A, Turaga A. OCP-driven hypertriglyceridaemia and recurrent acute pancreatitis. BMJ Case Rep 2023; 16:e257067. [PMID: 37798042 PMCID: PMC10565274 DOI: 10.1136/bcr-2023-257067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Recurrent acute pancreatitis poses a significant challenge in clinical management. In this case, a young, obese woman with metabolic syndrome presented with her third episode of acute pancreatitis within a span of 4 months. Due to unavailability, plasmapheresis could not be performed, and the patient was managed solely with pharmacological therapy. Initial evaluation revealed abdominal pain, tenderness and elevated laboratory markers. CT scan findings indicated pancreatic and peripancreatic oedema. Further investigations highlighted the presence of hypertriglyceridaemia and hypocalcaemia. As the patient was using oral contraceptive pills (OCP), it was crucial to consider their potential role in causing hypertriglyceridaemia. Consequently, the patient was advised to discontinue OCP use. Despite the lack of plasmapheresis, intensive medical management, including medication and lifestyle modifications, showed positive results. This case underscores the importance of recognising the association between OCP, hypertriglyceridaemia and recurrent pancreatitis in patients with metabolic syndrome.
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Affiliation(s)
- Samriddha Thapa
- Internal Medicine, Lower Bucks Hospital, Bristol, Pennsylvania, USA
| | - Akhil Allakky
- Internal Medicine, Lower Bucks Hospital, Bristol, Pennsylvania, USA
| | - Anjani Turaga
- Surgery, Gandhi Medical College, Secunderabad-Padmarao Nagar, India
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15
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Mae H, Nishizawa T, Wakai R, Arioka H. Haemosuccus pancreaticus associated with autosomal dominant polycystic kidney disease and chronic pancreatitis. BMJ Case Rep 2023; 16:e255855. [PMID: 37607761 PMCID: PMC10445341 DOI: 10.1136/bcr-2023-255855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Affiliation(s)
- Haruki Mae
- Department of General Internal Medicine, St. Luke's International Hospital, Chuo-ku, Japan
| | - Toshinori Nishizawa
- Department of General Internal Medicine, St. Luke's International Hospital, Chuo-ku, Japan
| | - Rikako Wakai
- Department of Radiology, St. Luke's International Hospital, Chuo-ku, Japan
| | - Hiroko Arioka
- Department of General Internal Medicine, St. Luke's International Hospital, Chuo-ku, Japan
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16
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Zhu C, Zeitouni F, Vaughan J, Santos AP. Laparoscopic management of combined cholecystogastric and cholecystocolonic fistulae. BMJ Case Rep 2023; 16:e255951. [PMID: 37558278 PMCID: PMC10414080 DOI: 10.1136/bcr-2023-255951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
Cholecystogastric and cholecystocolonic fistulae are rare sequelae of longstanding cholelithiasis and can complicate surgical management. Our case involves a male patient in his early 40s with a history of chronic cholelithiasis who presented to the emergency department with severe abdominal pain. Findings on imaging were consistent with acute calculous cholecystitis. During laparoscopic cholecystectomy, the presence of both cholecystogastric and cholecystocolonic fistulae was discovered. Fistula resection with cholecystectomy in a one-step approach using indocyanine green (ICG) angiography was performed. The patient improved and was discharged 3 days later. Laparoscopic management complemented by ICG angiography is a viable surgical approach in patients with cholecystogastric and cholecystocolonic fistulae.
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Affiliation(s)
- Christina Zhu
- Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Ferris Zeitouni
- Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Justin Vaughan
- Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
- Covenant Medical Center, Lubbock, Texas, USA
| | - Ariel P Santos
- Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
- Covenant Medical Center, Lubbock, Texas, USA
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17
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Santos L, Trigo A, Perdigoto D, Figueiredo P. Massive intramural duodenal haematoma: an unexpected post-ERCP complication. BMJ Case Rep 2023; 16:e256420. [PMID: 37463779 DOI: 10.1136/bcr-2023-256420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Affiliation(s)
- Luís Santos
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - André Trigo
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - David Perdigoto
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Pedro Figueiredo
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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18
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Shaikh OH, Sunil J, Prakash S, Vijaykumar C, Kumbhar US. Isolated pancreatic tuberculosis masquerading pancreatic malignancy. BMJ Case Rep 2023; 16:e254250. [PMID: 37402588 DOI: 10.1136/bcr-2022-254250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
Pancreatic tuberculosis is the rarest form of abdominal and extrapulmonary tuberculosis. We present a patient in his 40s who presented with pain abdomen and a fever. On examination, the patient had mild jaundice and right hypochondriac tenderness. Blood investigation was suggestive of obstructive jaundice. Imaging studies were representative of pancreatic head lesion, causing mild intrahepatic biliary radical dilatation. Endoscopic ultrasound-guided fine-needle aspiration done from the pancreatic head lesion was diagnostic of tuberculosis. The patient was started on antitubercular medications and responded well.
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Affiliation(s)
- Oseen Hajilal Shaikh
- Surgery, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, Pondicherry, India
| | - Julia Sunil
- Surgery, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, Pondicherry, India
| | - Sagar Prakash
- Surgery, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, Pondicherry, India
| | - Chellappa Vijaykumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, Pondicherry, India
| | - Uday Shamrao Kumbhar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, Pondicherry, India
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19
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Pina-Prata R, Rosa F, Fontes I, Morão S. Gastric duplication cyst of a bifid pancreas: cause of recurrent vomiting. BMJ Case Rep 2023; 16:e254019. [PMID: 37348926 DOI: 10.1136/bcr-2022-254019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
An infant girl first presented with recurrent episodes of non-bilious vomiting, having had five hospitalisations over the following months because of dehydration. Laboratory data showed no inflammatory response, normal pancreatic amylase, but increased lipase levels (between 67 and 425 U/L). Several abdominal ultrasound studies suggested an intestinal duplication cyst on left hypochondrium and, later, a dilated and irregular pancreatic duct. CT showed a bifid tailed pancreas and a change in the cyst's characteristics. A communication with the pancreatic duct was hypothesised, which was confirmed on MR cholangiopancreatography. On laparoscopic surgery, the cyst was confirmed to be at the end of the caudal side of the pancreatic bifid tail, having no communication with the stomach. Cystectomy with partial pancreatectomy was performed with pathological findings confirming a gastric duplication cyst originating from the pancreatic bifid tail. At latest follow-up, 4 months after surgery, she remains asymptomatic.
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Affiliation(s)
- Rita Pina-Prata
- Radiology Department, King's College London, Evelina London Children's Hospital, London, UK
- Radiology Department, Centro Hospitalar Universitário Lisboa Central EPE, Lisbon, Portugal
| | - Filipa Rosa
- Anatomical Pathology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisbon, Portugal
| | - Inês Fontes
- Paediatric Department, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central EPE, Lisbon, Portugal
| | - Sofia Morão
- Paediatric Surgery Department, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central EPE, Lisbon, Portugal
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20
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Kotha S, Berry P. Multi-system IgG4-related disease: the value of positron emission tomography. BMJ Case Rep 2023; 16:16/6/e253909. [PMID: 37263677 DOI: 10.1136/bcr-2022-253909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Affiliation(s)
- Sreelakshmi Kotha
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Philip Berry
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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21
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Zishan MA, Tee CL. Adenosquamous carcinoma of the gallbladder: a rare entity and dilemmas in its management. BMJ Case Rep 2023; 16:16/5/e254883. [PMID: 37236675 DOI: 10.1136/bcr-2023-254883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
Gallbladder carcinomas are the most common form of biliary tract malignancies with adenocarcinomas, by far the most common variant while adenosquamous (adenosquamous carcinoma of the gallbladder) or pure squamous cell carcinomas representing only 2%-10% of all gallbladder carcinomas. Despite being a minority, these tumours demonstrate aggressive behaviour resulting in delayed presentations with widespread local invasion. We report a case involving a woman in her 50s who was diagnosed on imaging with a suspected gallbladder malignancy in the community. She proceeded to have a laparoscopic extended cholecystectomy with a cuff of segment 4b and 5 liver resection and cystic node sampling revealing a T3N1 lesion which on further recommendation by the multidisciplinary team proceeded to have an open portal lymphadenectomy yielding another positive lymph node. This case report highlights the dilemmas encountered in the management of this rare histological subtype in the absence of well-defined treatment algorithm and evolving guidelines.
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Affiliation(s)
| | - Chin Li Tee
- General Surgery, Redcliffe Hospital, Redcliffe, Queensland, Australia
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22
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Dawid de Vera MT, Prieto Cuadra JD, Domínguez Pinos D, Hierro Martín I. Pleural empyema secondary to perforated diverticulosis due to biliary neoplasia infiltration. BMJ Case Rep 2023; 16:16/3/e250061. [PMID: 36898708 PMCID: PMC10008382 DOI: 10.1136/bcr-2022-250061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
A long-term female smoker presented to the emergency department with cough, greenish mucus and dyspnoea, without fever. The patient also reported abdominal pain and significant weight loss in recent months. Laboratory tests showed leucocytosis with neutrophilia, lactic acidosis and a faint left lower lobe consolidation on chest X-ray, for which she was admitted to the pneumology department and started on broad-spectrum antibiotherapy. After 3 days of clinical stability, the patient deteriorated rapidly, with worsening of analytical parameters and coma. The patient died a few hours later. Given the rapid and unexplained evolution of the disease, a clinical autopsy was requested, which revealed a left pleural empyema caused by perforated diverticula by neoplastic infiltration of biliary origin.
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Affiliation(s)
- Maria Teresa Dawid de Vera
- Unidad de Gestión Clínica (UGC) de Anatomía Patológica, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Juan Daniel Prieto Cuadra
- Unidad de Gestión Clínica (UGC) de Anatomía Patológica, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Málaga, Spain .,SYNLAB Pathology, SYNLAB Global Diagnosis, Barcelona, Spain
| | | | - Isabel Hierro Martín
- Unidad de Gestión Clínica (UGC) de Anatomía Patológica, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Málaga, Spain
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23
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has until now always been performed using a reusable non-sterile duodenoscope. The introduction of the new single-use disposable duodenoscope makes it possible to perform perioperative transgastric and rendezvous ERCP in an almost sterile manner. It also eliminates the risk of patient-to-patient transmission of infection in non-sterile settings. We present four patients who underwent different types of ERCP using a sterile single-use duodenoscope. This case report aims to demonstrate the use and the many potential advantages of the new disposable single-use duodenoscope in both sterile and non-sterile settings.
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Affiliation(s)
- Ronja Lagström
- Department of Surgery, Zealand University Hospital Koge, Køge, Denmark
| | - Svend Knuhtsen
- Department of Surgery, Zealand University Hospital Koge, Køge, Denmark
| | - Trine Stigaard
- Department of Surgery, Zealand University Hospital Koge, Køge, Denmark
| | - Mustafa Bulut
- Department of Surgery, Zealand University Hospital Koge, Køge, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
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24
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Naresh D, de Kock S. Acute pancreatitis presenting as acute scrotum. BMJ Case Rep 2023; 16:16/2/e253867. [PMID: 36810327 PMCID: PMC9945011 DOI: 10.1136/bcr-2022-253867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Acute pancreatitis can lead to pancreatic and peripancreatic collections that can spread in the retroperitoneum to varying extents based on the severity of the pancreatitis. We present here an unusual case of pancreatitis where the patient presented with an acute scrotum as a result of extension of peripancreatic inflammation to the scrotum.
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Affiliation(s)
- Divya Naresh
- Department of Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Servaise de Kock
- Department of Surgery, Bairnsdale Regional Health Service, Bairnsdale, Victoria, Australia
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25
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Eng NL, Tiwari K, Chen G, Peng JS. Metachronous metastatic pancreatoblastoma to the liver in an elderly patient misdiagnosed as pancreatic acinar cell carcinoma. BMJ Case Rep 2022; 15:15/12/e252910. [PMID: 36585053 PMCID: PMC9809231 DOI: 10.1136/bcr-2022-252910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
A woman in her 80s was evaluated for a liver mass. She had a history of what was reported as pancreatic acinar cell carcinoma resected with a pancreatoduodenectomy 10 years prior at another institution. Liver biopsy showed metastatic pancreatoblastoma (PB) and staging imaging showed no evidence of additional metastatic disease. She underwent laparoscopic non-anatomic partial hepatectomy and recovered uneventfully. The liver pathology was reviewed along with slides from her initial pancreatoduodenectomy, and both were noted to be consistent with PB. PB contains similar histological characteristics to pancreatic acinar cell carcinoma. Distinguishing between the two diagnoses is critical for accurately defining the prevalence, clinical course and prognosis associated with PB.
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Affiliation(s)
- Nina L Eng
- Department of General Surgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Kriti Tiwari
- Department of Pathology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Guoli Chen
- Department of Pathology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - June S Peng
- Division of Surgical Oncology, Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
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26
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Yu C, Lokan J, Jackett L, Nikfarjam M, Mills C. Intraductal tubulopapillary neoplasm. BMJ Case Rep 2022; 15:15/12/e246398. [PMID: 36549752 PMCID: PMC9791450 DOI: 10.1136/bcr-2021-246398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A man aged above 70 years old with a medical history of ulcerative colitis presented with unintentional weight loss. A pancreatic mass associated with pancreatic duct dilatation was detected on imaging procedures. Initial investigations including fine needle aspiration and cytology examination were inconclusive. A diagnosis of intraductal tubulopapillary neoplasm (ITPN) was made with histopathology and immunohistochemistry examination on a surgically resected specimen. Two years after surgery, the patient remained well with no radiological evidence of recurrence.ITPN is a rare pancreatic duct tumour with limited case reports in medical literature. Risk factors are not well established. We report the first case of ITPN occurring in a patient with ulcerative colitis. A typical presentation of this rare tumour is reported to encourage clinicians to consider ITPN in the differential diagnoses of a pancreatic mass.
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Affiliation(s)
- Catherine Yu
- General Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Julie Lokan
- Pathology, Austin Health, Melbourne, Victoria, Australia
| | - Louise Jackett
- Pathology, Austin Health, Melbourne, Victoria, Australia
| | - Mehrdad Nikfarjam
- Hepatobiliary/Transplant Unit, Department of Surgery, Austin Hospital, Melbourne, Vicotira, Australia
| | - Christopher Mills
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Churchill, Victoria, Australia
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27
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Mark JD, Park T, Velez Quinones V, Isaac S. Rare extension of pancreatic pseudocyst with Mycobacterium abscessus into the iliopsoas muscle. BMJ Case Rep 2022; 15:15/11/e252777. [PMID: 36319038 PMCID: PMC9628508 DOI: 10.1136/bcr-2022-252777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Pancreatic pseudocyst is a well-known complication of both acute and chronic pancreatitis. Although extension into other anatomical sites is common, extension into the retrofascial space causing an iliopsoas abscess is exceedingly rare. Although its low incidence creates a diagnostic challenge for clinicians, early diagnosis is essential to prevent significant complications and poor patient outcomes. We present a case of iliopsoas abscess with unusual culture fluid growth in the setting of acute on chronic pancreatitis secondary to extension of a pancreatic pseudocyst. We also offer a brief review of the literature and pathophysiology of the condition.
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Affiliation(s)
- Justin David Mark
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Travis Park
- Department of Internal Medicine, HCA Florida JFK Hospital, Atlantis, Florida, USA
| | | | - Shaun Isaac
- Department of Internal Medicine, HCA Florida JFK Hospital, Atlantis, Florida, USA
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28
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Tellez R, Bromfield B, Basinger H, Slivka A. IgG4-related disease presenting with multiorgan involvement. BMJ Case Rep 2022; 15:15/6/e250637. [PMID: 35649620 DOI: 10.1136/bcr-2022-250637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a rare fibroinflammatory immune-mediated condition which can affect multiple organ systems and form mass-like lesions. Initial presentation can mimic other diseases such as pancreatic malignancy when there is pancreatic involvement or tuberculosis (TB) when there are pulmonary lesions or hypertrophic pachymeningitis (HP). Here, we report a novel case of IgG4-RD presenting as bilateral subdural haematomas with additional findings. Our patient is a male who presented with headaches and blurred vision. Physical examination showed disconjugate gaze with a fixed pupil. Trauma survey radiologic imaging revealed a pancreatic mass concerning for malignancy. Subsequent workup found hypophysitis with optic chiasm compression and hypopituitarism, mediastinal lymphadenopathy and HP. Laboratory values showed an elevated serum IgG4 level and latent TB. Our case adds to the existing IgG4-RD literature by highlighting a unique presentation. It is important to maintain it on the differential diagnosis especially in multisystemic presentations with competing diagnoses.
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Affiliation(s)
| | | | | | - Adam Slivka
- Gastroenterology and Hepatology, UPMC, Pittsburgh, Pennsylvania, USA
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29
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Bartsokas C, Voulgaris S, Economopoulos N, Vassiliu P. Giant gastric ulcer penetrating the pancreas in a haemodynamically unstable patient. BMJ Case Rep 2022; 15:15/5/e250527. [PMID: 35568414 DOI: 10.1136/bcr-2022-250527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Christos Bartsokas
- 4th Surgical Department, Panepistemiako Geniko Nosokomeio Attikon, Athens, Greece.,4th Department of Surgery, Agrinio General Hospital, Agrinio, Greece
| | - Sotirios Voulgaris
- 4th Department of Surgery, General University Hospital Attikon, Athens, Greece
| | - Nikolaos Economopoulos
- Second Department of Radiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital 'Attikon', Athens, Greece
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30
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Tee CL, Lin EY, Bundele MM, Low JK. Rare case of pancreatic lipomatous hamartoma. BMJ Case Rep 2022; 15:e248132. [PMID: 35393275 PMCID: PMC8990702 DOI: 10.1136/bcr-2021-248132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/09/2022] Open
Abstract
A middle-aged man had an incidental finding of 10.1 cm lipomatous mass arising from pancreatic body/neck detected on CT scan. He was asymptomatic. He underwent surgical resection of the mass due to concern for malignancy. His postoperative course was complicated by a high-volume pancreatic leak of approximately 900 mL/day. He underwent endoscopic retrograde cholangiopancreatography and insertion of a pancreatic stent, with some improvement in the pancreatic leak. His leak eventually settled after 3 months. The final histopathology showed lobules of mature adipocytes with small islands of disorganised benign pancreatic ducts and acini interspersed within them, suggestive of pancreatic hamartoma of lipomatous variant. Pancreatic lipomatous hamartomas are rare and are often diagnosed on final histopathology when the initial resection was performed due to diagnostic uncertainty or concern for malignancy. It is a benign lesion with an indolent course and must be discriminated from other lipomatous lesions of the pancreas. An awareness of the condition is important to help guide management.
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Affiliation(s)
- Chin Li Tee
- Department of Hepato-Pancreatico-Biliary Surgery, Tan Tock Seng Hospital, Singapore
| | - Eliz Yuyuan Lin
- Department of Hepato-Pancreatico-Biliary Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Jee Keem Low
- Department of Hepato-Pancreatico-Biliary Surgery, Tan Tock Seng Hospital, Singapore
- Department of Hepato-Pancreatico-Biliary Surgery, Tan Tock Seng Hospital, Singapore
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31
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Farrugia P, Portelli C, Buhagiar M. Rare cause of deranged liver profile in pregnancy. BMJ Case Rep 2022; 15:e247539. [PMID: 35351747 PMCID: PMC8966539 DOI: 10.1136/bcr-2021-247539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2022] [Indexed: 11/04/2022] Open
Abstract
We present the case of a 33-year-old pregnant woman with an abnormal liver profile secondary to liver metastases from colon cancer. The patient presented in her third trimester with non-specific symptoms. Blood tests revealed a cholestatic liver picture, initially attributed to prurigo gravidarum. However, following a normal vaginal delivery, her symptoms persisted and the liver profile failed to return to baseline. This led to further investigations including a CT scan of the abdomen-revealing a transverse colonic tumour with extensive liver involvement. Biopsy of the liver confirmed an adenocarcinoma of colonic origin, and subsequently the patient underwent a right hemicolectomy followed by systemic chemotherapy.
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32
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Warsi A, Wilson AN, Tong KS, Gan J, Chong HL. Mini-laparoscopic cholecystectomy: evolution of a new technique. BMC Surg 2021; 21:391. [PMID: 34732183 PMCID: PMC8567624 DOI: 10.1186/s12893-021-01389-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/27/2021] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Since the first laparoscopic cholecystectomy (LC) in 1985, there has been much advancement in laparoscopic surgery in terms of reduction in number and size of ports. We report a new technique of performing mini laparoscopic cholecystectomy using only three ports, 5 mm each. The indications of this procedure include GB polyps, GB dyskinesia, microlithiasis, and idiopathic pancreatitis. CASE PRESENTATION In this case report, we present a new technique that has been performed safely in a 49-year-old male patient with pancreatitis caused by microlithiasis. This was performed using a novel three port procedure consisting of only 5 mm ports, and he was discharged as a day case without complications. Informed patient consent was obtained. CONCLUSIONS The fundamentals of this mini-LC technique remain the same as that of a standard laparoscopic cholecystectomy throughout the procedure. It is a feasible option in selected cases, and it has the potential to further augment the inherent benefits of minimal access surgery namely less analgesia, improved cosmesis and faster recovery. Further trials will help ascertain its potential advantages.
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Affiliation(s)
- Ali Warsi
- General Surgery, University Hospitals of Morecambe Bay NHS Foundation, Lancaster, UK
| | - Andrew Natsuki Wilson
- General Surgery, University Hospitals of Morecambe Bay NHS Foundation, Lancaster, UK
| | - Kin Seng Tong
- General Surgery, University Hospitals of Morecambe Bay NHS Foundation, Lancaster, UK
| | - Jonathan Gan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ho Lun Chong
- General Surgery, University Hospitals of Morecambe Bay NHS Foundation, Lancaster, UK. .,, 23 Nightingale House, Pointer Court, Lancaster, LA1 4JT, UK.
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33
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Abstract
A 78-year-old man presented to the accident and emergency department with acute abdominal pain. A CT scan done to investigate the pain showed an intra-abdominal abscess medial to the caecum and an incidental exophytic lesion in the gall bladder. This was excised during surgery and sent for histological examination. Histology showed a ciliated foregut cyst of the gall bladder. A literature review revealed that this was the 13th case worldwide, as ciliated foregut cysts are usually found either above the diaphragm or in the liver. It was also the largest cyst described, with 45 mm diameter. So far none of these cysts found in the gall bladder have shown malignant transformation, though those found in the liver have been known to become malignant. Due to histological similarity, excision of ciliated foregut cysts of the gall bladder should be considered as there is still a risk of malignant transformation.
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Affiliation(s)
| | - Ivan Blazic
- Department of Surgery, Mater Dei Hospital, Msida, Malta
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34
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Khalid S, Bilal A, Asad-Ur-Rahman FNU, Pratley R. Postgastric bypass hypoglycaemia in a patient with end-stage renal disease: a diagnostic and management pitfall. BMJ Case Rep 2017; 2017:bcr-2017-220600. [PMID: 28619742 DOI: 10.1136/bcr-2017-220600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Roux-en-Y gastric bypass (RYGB) surgery is currently one of the most popular procedures to aid weight loss. Hypoglycaemia associated with gastric bypass surgery is an underdiagnosed but life-threatening potential consequence of the surgical procedure. We present a case of a 44-year-old woman with end-stage renal disease presenting with refractory hypoglycaemia after 10 years of RYGB. Extensive history and work-up excluded medications, renal disease, insulinoma and dumping syndrome as the cause of hypoglycaemia. Dietary modifications or pharmacological trial of drugs did not ameliorate her symptoms with progressive worsening of hypoglycaemia leading to continuous dextrose infusion. Distal pancreatectomy was performed with subsequent resolution of hypoglycaemia. Surgical pathology results showed diffuse hyperplastic islet cells, confirming the diagnosis of postgastric bypass hypoglycaemia.
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Affiliation(s)
- Sameen Khalid
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA.,Department of Internal Medicine, Florida Hospital, Orlando, Florida, USA
| | - Anika Bilal
- Department of Research, Florida Hospital, Orlando, Florida, USA
| | | | - Richard Pratley
- Department of Endocrinology, Florida Hospital, Orlando, Florida, USA
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35
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Abstract
Thrombotic microangiopathy (TMA) occurring after acute pancreatitis is rarely described. Without prompt intervention, TMA can be, and often is, lethal, so prompt recognition is important. Here, we present a case of a 61-year-old woman with a history of alcohol misuse who presented with epigastric pain, nausea and vomiting after binge drinking. Elevated serum lipase and imaging were suggestive of acute-on-chronic pancreatitis. Although the patient's symptoms of acute pancreatitis subsided, her anaemia, thrombocytopenia and acute kidney injury worsened. A peripheral blood smear revealed schistocytes, prompting suspicion for TMA. Therapeutic plasma exchange (TPE) was promptly initiated and she completed 10 TPE sessions that improved her anaemia and serum creatinine and resolved the thrombocytopenia. Since TPE was effective and the ADAMTS13 assay revealed 55% activity in the absence of anti-ADAMTS13 IgG prior to initiation of therapy, a confident diagnosis of TMA caused by acute pancreatitis was made. There was no evidence of relapse 2 years later.
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Affiliation(s)
- Kevin Singh
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Ahmed Jamal Nadeem
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Behzad Doratotaj
- Department of Haematology and Oncology, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
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36
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Affiliation(s)
- Jie Lim
- General Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Johnathan Porter
- General Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Haren Varia
- Radiology, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Stephen Pettit
- General Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
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37
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Abstract
Enterococcus casseliflavus is a rare non-faecium, non-faecalis, vancomycin-resistant enterococcus (VRE) that is responsible for up to 2% of all enterococcal infections. Septicaemia with this bacterium is usually seen in older patients with multiple comorbidities who have had several previous hospitalisations. Septicaemia with E. casseliflavus portends a poorer prognosis, and treatment usually involves administration of antienterococcal beta-lactams or anti-VRE medications such as linezolid or daptomycin. We present such a case of a 75-year-old man who developed E. casseliflavus septicaemia of presumably hepatobiliary origin and responded well to treatment with intravenous beta-lactams.
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Affiliation(s)
- Rajanshu Verma
- Department of Hospital Medicine, Augusta Health, Fishersville, Virginia, USA.,Hospital Medicine, United Hospital, Allina Health, St Paul, Minnesota, USA
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38
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Matos LV, Moniz P, Dantas JO, Botella A. A rare view: giant liver abscess with underlying liver metastases. BMJ Case Rep 2017; 2017:bcr-2017-219873. [PMID: 28490480 DOI: 10.1136/bcr-2017-219873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Patricia Moniz
- Medicina III, Hospital São Francisco Xavier-Centro Hospitalar Lisboa Ocidental/NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | - Arturo Botella
- Department of Internal Medicine, Hospital Sao Francisco Xavier, Lisboa, Portugal
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39
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Abu Ghanimeh M, Abuamr K, Sadeddin E, Yousef O. Severe chronic diarrhoea secondary to primary lymph node gastrinoma. BMJ Case Rep 2017; 2017:bcr-2016-216855. [PMID: 28446479 PMCID: PMC5534825 DOI: 10.1136/bcr-2016-216855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2017] [Indexed: 11/03/2022] Open
Abstract
The existence of primary lymph node (LN) gastrinoma is questionable and controversial. In fact, the presence of gastrinoma in such uncommon site raises the possibility of metastasis from another occult primary site. An extensive evaluation and careful follow-up is always warranted. A female aged 48 years presented with chronic abdominal pain and watery diarrhoea. Her serum gastrin and chromogranin were elevated, and an underlying gastrinoma was suspected. Further evaluation with an octreotide scan, an endoscopic ultrasound and a secretin stimulation test confirmed the diagnosis. Further evaluation for multiple endocrine neoplasia-1 syndrome was negative. She underwent a surgical enucleation near the head of the pancreas. No other lesions were found after careful exploration of the gastrinoma triangle. Histology showed a LN with a neuroendocrine tumour that tested positively with gastrin and chromogranin stains. Her symptoms resolved postoperatively, her serum gastrin normalised and a repeated octreotide scan was negative.
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Affiliation(s)
- Mouhanna Abu Ghanimeh
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Khalil Abuamr
- Gastroenterology, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Esmat Sadeddin
- Gastroenterology, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Osama Yousef
- Gastroenterology, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
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40
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Thillai M, Sethi P, Narayana Menon R, Puthukudiyil Kader N. Cystic artery pseudoaneurysm following acute necrotising pancreatitis. BMJ Case Rep 2017; 2017:bcr-2016-218891. [PMID: 28446484 DOI: 10.1136/bcr-2016-218891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cystic artery pseudoaneurysm is a rare pathology. Of the 20 cases reported so far, chronic cholecystitis and iatrogenic biliary injury form the majority of causes. Currently, there is no published report of such pseudoaneurysms caused secondary to pancreatitis, hence the management in such a scenario is unclear. We hereby present the first such report of cystic artery pseudoaneurysm occurring as a sequel of acute necrotising pancreatitis. A 33-year-old man who recovered from a recent attack of acute pancreatitis was readmitted for melena and fever. Computed tomography of abdomen revealed blood in the gall bladder with pericholecystic blush and resolving pancreatic necrosis. Percutaneous transarterial embolisation of the cystic artery was done. This stabilised the patient but persistent sepsis and clinical deterioration warranted a surgical exploration and cholecystostomy. Hence, transarterial embolisation followed by surgery in selected cases can be an ideal management protocol.
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Affiliation(s)
- Manoj Thillai
- Department of Surgical Gastroenterology and Liver transplantation, Amrita Institute of Medical sciences, Amrita vishwavidyapeetham, Ponekkara, Kochi, Kerala, India
| | - Pulkit Sethi
- Department of Surgical Gastroenterology and Liver transplantation, Amrita Institute of Medical sciences, Amrita vishwavidyapeetham, Ponekkara, Kochi, Kerala, India
| | - Ramachandran Narayana Menon
- Department of Surgical Gastroenterology and Liver transplantation, Amrita Institute of Medical sciences, Amrita vishwavidyapeetham, Ponekkara, Kochi, Kerala, India
| | - Nazar Puthukudiyil Kader
- Department of Radiodiagnosis, Amrita Institute of Medical Sciences, Amrita vishwavidyapeetham, Ponekkara, Kochi, Kerala, India
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Carmody D, Park SY, Ye H, Perrone ME, Alkorta-Aranburu G, Highland HM, Hanis CL, Philipson LH, Bell GI, Greeley SAW. Continued lessons from the INS gene: an intronic mutation causing diabetes through a novel mechanism. J Med Genet 2015; 52:612-6. [PMID: 26101329 DOI: 10.1136/jmedgenet-2015-103220] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 06/03/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Diabetes in neonates usually has a monogenic aetiology; however, the cause remains unknown in 20-30%. Heterozygous INS mutations represent one of the most common gene causes of neonatal diabetes mellitus. METHODS Clinical and functional characterisation of a novel homozygous intronic mutation (c.187+241G>A) in the insulin gene in a child identified through the Monogenic Diabetes Registry (http://monogenicdiabetes.uchicago.edu). RESULTS The proband had insulin-requiring diabetes from birth. Ultrasonography revealed a structurally normal pancreas and C-peptide was undetectable despite readily detectable amylin, suggesting the presence of dysfunctional β cells. Whole-exome sequencing revealed the novel mutation. In silico analysis predicted a mutant mRNA product resulting from preferential recognition of a newly created splice site. Wild-type and mutant human insulin gene constructs were derived and transiently expressed in INS-1 cells. We confirmed the predicted transcript and found an additional transcript created via an ectopic splice acceptor site. CONCLUSIONS Dominant INS mutations cause diabetes via a mutated translational product causing endoplasmic reticulum stress. We describe a novel mechanism of diabetes, without β cell death, due to creation of two unstable mutant transcripts predicted to undergo nonsense and non-stop-mediated decay, respectively. Our discovery may have broader implications for those with insulin deficiency later in life.
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Affiliation(s)
- David Carmody
- Departments of Medicine and Pediatrics, Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, The University of Chicago, Chicago, Illinois, USA
| | - Soo-Young Park
- Departments of Medicine and Pediatrics, Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, The University of Chicago, Chicago, Illinois, USA
| | - Honggang Ye
- Departments of Medicine and Pediatrics, Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, The University of Chicago, Chicago, Illinois, USA
| | - Marie E Perrone
- Departments of Medicine and Pediatrics, Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, The University of Chicago, Chicago, Illinois, USA
| | - G Alkorta-Aranburu
- Department of Human Genetics, The University of Chicago, Chicago, Illinois, USA
| | - Heather M Highland
- Human Genetics Center, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Craig L Hanis
- Human Genetics Center, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Louis H Philipson
- Departments of Medicine and Pediatrics, Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, The University of Chicago, Chicago, Illinois, USA
| | - Graeme I Bell
- Departments of Medicine and Pediatrics, Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, The University of Chicago, Chicago, Illinois, USA
| | - Siri Atma W Greeley
- Departments of Medicine and Pediatrics, Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, The University of Chicago, Chicago, Illinois, USA
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