Ultrasound-guided thrombin injection for pseudoaneurysms: a case series at a local hospital

Post-catheterization pseudoaneurysms are increasingly prevalent due to widespread use of endovascular procedures. Ultrasound-guided thrombin injection has emerged as a treatment of choice for these pseudoaneurysms. We review our experience performing this procedure for a series of cases from 2007 to 2010 with different clinical manifestations at a single hospital in Hong Kong. We achieved a high technical success rate with no complications.

Primary hepatic peripheral T-cell lymphoma in a patient with chronic hepatitis B infection

We report a case of primary hepatic peripheral T-cell lymphoma in a patient with hepatitis B virus-related cirrhosis. This patient presented with a solitary hepatic lesion with computed tomography and magnetic resonance imaging features that did not resemble hepatocellular carcinoma. Subsequent biopsy of the lesion revealed that it was a peripheral T-cell lymphoma. The patient was successfully treated with multi-agent chemotherapy followed by radiofrequency ablation. Although hepatocellular carcinoma is the most frequently encountered primary hepatic tumour in patients with hepatitis B virus-related cirrhosis, primary hepatic lymphoma should also be borne in mind. Nevertheless, primary hepatic lymphoma is a rare entity, and has no proven association with chronic hepatitis B infection.

Splenic tuberculosis associated with monoclonal gammopathy of undetermined significance and pericarditis

Tuberculosis usually affects the respiratory system, but it may present atypically involving multiple systems, extrapulmonary systems, and manifest as a protein disorder. Here we report a case of splenic tuberculosis associated with monoclonal gammopathy of undetermined significance, and pericarditis. The diagnosis, confirmed by a plugged biopsy of the spleen, precluded the need for splenectomy in this patient and allowed prompt initiation of treatment, thereby avoiding the complications of tuberculous pericarditis and splenic infection.

Nodular regenerative hyperplasia of the liver associated with systemic lupus erythematosus: three cases

Nodular regenerative hyperplasia of the liver, characterised by regenerative nodules distributed throughout the liver in the absence of fibrosis, is a rare but important complication of systemic lupus erythematosus. The main consequence of nodular regenerative hyperplasia of the liver is non-cirrhotic portal hypertension. This condition is probably underdiagnosed, as many of these patients may remain asymptomatic. Furthermore, nodular regenerative hyperplasia of the liver may be misdiagnosed as cirrhosis. We describe three female patients with nodular regenerative hyperplasia of the liver associated with systemic lupus erythematosus. All three patients have clinical manifestations of portal hypertension, and all were initially misdiagnosed as having cryptogenic cirrhosis.

Spontaneous intra-hepatic haemorrhage in a patient with fever of unknown origin

Polyarteritis nodosa is a systemic necrotising vasculitis that affects the small- and medium-sized arteries. Multifocal aneurysmal formation in the renal, hepatic, and mesenteric vasculature is a hallmark of this condition, and spontaneous aneurysmal rupture may occur, resulting in life-threatening haemorrhage. We describe a 42-year-old man who initially presented with fever of unknown origin. A diagnosis could not be reached at that time despite extensive investigations. The fever subsided spontaneously after 8 weeks, and the patient remained well for 6 years until he was admitted again for evaluation of fever. During his hospital stay, he developed a spontaneous massive intra-hepatic haemorrhage resulting in hepatic rupture and a haemoperitoneum. The bleeding was controlled at emergency laparotomy. An abdominal angiography demonstrated multiple microaneurysms in the hepatic and mesenteric arterial vasculature. The clinical findings suggested polyarteritis nodosa, and the source of bleeding was probably a ruptured intra-hepatic artery aneurysm.

Unique hepatic imaging features in a patient with nodular regenerative hyperplasia of the liver associating with systemic lupus erythematosus

Nodular regenerative hyperplasia (NRH) of the liver, characterized by regenerative nodules distributed throughout the liver in the absence of fibrosis, is a rare but important complication of systemic lupus erythematosus (SLE). The main consequence of NRH is non-cirrhotic portal hypertension. We describe a female patient who had immune thrombocytopenia in association with elevated liver enzymes and evidence of portal hypertension as initial manifestations of SLE. Computed tomographic scan and magnetic resonance imaging of the liver in this patient showed enhancing periportal tubular structures distributed throughout the liver. The diagnosis of NRH was eventually disclosed by transcutaneous needle liver biopsy. The pattern of radiological abnormality in this patient has not been described previously in NRH. In addition, we believe this is a first reported case of SLE presenting with immune thrombocytopenia in association with NRH.

Pyogenic Liver Abscesses Caused byKlebsiella pneumoniae: US Appearance and Aspiration Findings

PURPOSE

To retrospectively compare the ultrasonographic (US) appearance and amount of pus obtained at initial aspiration for liver abscesses caused by Klebsiella pneumoniae with those for liver abscesses caused by other bacterial pathogens.

MATERIALS AND METHODS

This study had medical ethics committee approval; informed consent was not required. Asian patients with pyogenic liver abscesses in a 5-year period were included. Abscess clinical, laboratory, and microbiologic characteristics and treatment and outcome were analyzed. US images were classified according to the size of the largest liver abscess, the echogenic pattern of the lesion, the presence of any echogenic debris within the lesion, increased through transmission in the posterior aspect of the lesion, and the lesion margin. Clinical and US characteristics of patients with K pneumoniae monomicrobial liver abscesses and those with non-K pneumoniae monomicrobial or polymicrobial liver abscesses were compared. The chi(2) or Fisher exact test was used for categorical variables; the Student t test was used for continuous variables.

RESULTS

There were 120 patients with pyogenic liver abscesses. Median patient age was 69 years (range, 13-94 years). Fifty-nine patients were male, and 61 were female. Fifty patients with K pneumoniae monomicrobial and 33 patients with non-K pneumoniae monomicrobial or polymicrobial liver abscesses underwent US. K pneumoniae monomicrobial liver abscesses were associated with diabetes mellitus (P < .001), higher blood glucose levels at admission (P < .05), predominantly solid US appearances (P < .001), irregular or indistinct lesion margins (P < .05), less than 2 mL of pus aspirated (P < .001), and longer duration of antibiotic treatment (P < .05).

CONCLUSION

A predominantly solid appearance at US is associated with K pneumoniae monomicrobial liver abscess. K pneumoniae liver abscess is associated with a much smaller quantity of pus at initial aspiration.

Hepatic portal venous gas complicating septic thrombophlebitis of the superior mesenteric vein

Hepatic portal venous gas is a rare radiological finding with a wide spectrum of underlying pathologies. We describe a case of hepatic portal venous gas due to septic thrombophlebitis of the superior mesenteric vein. The clinical management of portomesenteric venous gas and the importance of computed tomography in delineating its underlying causes are discussed.

Oesophageal tuberculosis mimicking oesophageal carcinoma

Tuberculous involvement of the oesophagus is rare, and is usually caused by direct spread from adjacent afflicted structures. We report an 83-year-old male patient with oesophageal tuberculosis secondary to tuberculous mediastinal lymphadenitis who presented with non-specific symptoms of anorexia and lethargy. Upper gastro-intestinal endoscopy revealed an ulcerative tumour-like lesion in the mid-oesophagus suggesting oesophageal carcinoma. Repeated endoscopic biopsies revealed a non-specific acute-on-chronic inflammation consisting of non-caseating granulomas, with no evidence of malignancy. Endoscopic ultrasonography demonstrated that the oesophageal lesion was secondary to direct extension of mediastinal lymphadenopathy. The diagnosis of tuberculosis was eventually confirmed by histological and microbiological analysis of a surgically excised cervical lymph node. The patient responded promptly to treatment with antituberculous drugs. We suggest that oesophageal tuberculosis has to be kept in mind in the differential diagnosis of oesophageal ulcerohypertrophic lesions.

Intestinal tuberculosis in a regional hospital in Hong Kong: a 10-year experience

OBJECTIVE

To study the clinical and pathological characteristics of patients with intestinal tuberculosis.

DESIGN

Retrospective study.

SETTING

United Christian Hospital, Hong Kong.

PATIENTS

Patients with intestinal tuberculosis diagnosed between January 1995 and December 2004 inclusive.

RESULTS

The median age of the 13 male and 9 female patients was 53 years (range, 12-81 years). Nineteen (86%) had a definitive diagnosis of intestinal tuberculosis confirmed by the presence of caseating granulomas and/or acid-fast bacilli in histological specimens. In three (14%) the diagnosis was based on histology revealing non-caseating granulomas and a positive response to anti-tuberculous treatment. Common symptoms included abdominal pain (82%), diarrhoea (55%), weight loss (55%), and fever (45%). Three (14%) of the patients were complicated by intestinal obstruction, and another two (9%) had intestinal perforation. Four (18%) had concomitant active pulmonary tuberculosis. The most frequently involved site was the ileocaecal region, which was affected in 19 (86%) patients. Other sites included the jejunum, ascending and sigmoid colon. The diagnosis of intestinal tuberculosis was facilitated by examination of colonoscopic biopsy specimens (11 patients), and by examination of resected surgical specimens in the remainder. Two patients died from terminal malignancy. The remainder completed anti-tuberculous therapy and responded satisfactorily.

CONCLUSIONS

The diagnosis of intestinal tuberculosis is difficult due to the lack of specific signs or symptoms. Colonoscopy with ileoscopy are useful tools in the search for colonic and terminal ileal tuberculosis. Surgical exploration is reserved for equivocal cases and for those who present as emergencies.

Recurrent variceal bleeding in a young woman

Congenital hepatic fibrosis is an uncommon fibrocystic disorder affecting the intrahepatic bile ducts. It has autosomal recessive inheritance. The main consequence of this condition is portal hypertension and it is often misdiagnosed as cirrhosis. Patients with congenital hepatic fibrosis usually present during childhood or early adolescence with oesophageal variceal bleeding. Portosystemic shunt surgery is the treatment of choice for these patients as the risk of postoperative hepatic encephalopathy is low. We report a patient with congenital hepatic fibrosis who presented with oesophageal variceal bleeding at the age of 16 years, initially misdiagnosed as having cryptogenic liver cirrhosis. The patient experienced two further episodes of oesophageal variceal bleeding in subsequent years. She eventually underwent portosystemic shunt surgery. One year after the operation, the shunt remained patent on Doppler ultrasonography, and there had been no further episodes of variceal bleeding post-surgery.

Epigastric pain in a patient with neurofibromatosis type 1

Patients with neurofibromatosis type 1 are at increased risk of developing carcinoid tumours of the duodenum, particularly in the ampulla of Vater. Aggressive surgery with pancreatoduodenectomy is recommended for all ampullary carcinoid tumours because of their propensity to metastasise. We report a case of a 43-year-old woman with neurofibromatosis type 1, who presented with recurrent epigastric pain for 15 months. Evaluation using magnetic resonance cholangiopancreatography and side-viewing duodenoscopy revealed a submucosal tumour at the ampulla of Vater causing pancreatobiliary ductal obstruction and dilation. The ampullary tumour was overlooked initially by forward-viewing endoscopy. The patient subsequently underwent pancreatoduodenectomy. Histological examination of the surgically resected specimen confirmed the presence of a carcinoid tumour, with metastasis to peri-pancreatic lymph nodes. She remained asymptomatic 10 months after surgery.