1/23. Nonoperative management of pancreatic pseudocysts. Problems in differential diagnosis.CONCLUSION: The evaluation of pancreatic cystic lesions entails a misdiagnosis risk. awareness of the problem, knowledge of the natural history of these lesions, and meticulous posttreatment follow-up can reduce the consequences of diagnostic errors. If all these precautions are adopted, pancreatic pseudocysts can be safely treated nonoperatively. BACKGROUND: The accurate diagnosis of pancreatic cystic lesions remains a problem. The aim of this study was to ascertain the incidence of and the reasons the diagnostic errors occurred in a series of pseudocysts drained percutaneously and to compare these data to those reported in the literature. methods: Data from 70 patients bearing one or more pseudocysts who underwent a percutaneous drainage were reviewed. The pretreatment workup included medical history, physical examination, ultrasound (US) and computed tomography (CT) scans, amylase assay in both the serum and the cystic fluid, culture and cytology of the cystic fluid. After removal of the drainage, the minimum follow-up period was 12 mo. RESULTS: Four patients died, and two cancer-associated pseudocysts were identified before removal of the drainage. Sixty-four patients were followed up for a mean of 51.9 mo (range 12-154 mo). A third cancer and a mucinous cystic tumor, fully communicating with the main duct, were further detected during this period.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/23. Coexistence of an endocrine tumour in a serous cystadenoma (microcystic adenoma) of the pancreas, an unusual association.A pancreatic endocrine tumour arising within a serous cystadenoma is reported. A 49 year old woman was admitted with a history of epigastric pain, nausea, vomiting, and weight loss of two months duration. She had been diabetic for 12 years. An epigastric mass was palpated in the physical examination, and computed tomography revealed a multiloculated cystic lesion in the pancreas. Pathological examination of the pancreatic tumour revealed the coexistence of a serous cystadenoma and an endocrine tumour. The endocrine tumour, which was located inside the serous cystadenoma, was 1 cm in diameter. The first case of a serous cystadenoma of the pancreas containing a pancreatic endocrine tumour was reported in the literature recently. This paper reports another incidentally found pancreatic endocrine tumour arising within a serous cystadenoma.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
3/23. Preoperative diagnosis of pancreatic leiomyosarcoma.BACKGROUND: The low incidence of pancreatic leiomyosarcoma is responsible for the small number of cases correctly diagnosed preoperatively, the tumor being frequently confused with benign pancreatic lesions. RESULTS: We describe a symptom free 52-yr-old male bearing an abdominal mass incidentally found at physical examination. Imaging techniques revealed a nonhomogenous large mass at the head of the pancreas that dislodged the portal vein and the superior mesenteric vein. Increased metabolic activity in the tumor area demonstrated by 18F-fluorodeoxyglicose positron emission tomography scan allowed the diagnosis of a malignant lesion. The patient was operated on and a pylorus preserving pancreatoduodenectomy performed. The pathology diagnosis was a low grade leiomyosarcoma. immunohistochemistry revealed positivity for vimentin and smooth muscle specific actin. The clinical course was uneventful after 2 yr follow-up. CONCLUSION: Pancreatic leiomyosarcoma may be preoperatively diagnosed by image techniques and differentiated from benign lesions by means of fluorodeoxyglicose positron emission tomography scanning (FDGPET).- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
4/23. Lessons to be learned: a case study approach insulinoma presenting as a change in personality.A 43-year-old man presented with attacks of altered behaviour over a short period of time; they were associated with episodes of hypoglycaemia. The clinical suspicion of insulinoma prompted investigations that quickly established serum insulin and c-peptide levels to be elevated at the times when blood glucose values were low. A physical lesion was found in the head of the pancreas by means of computerised tomography and endo-duodenal ultrasound scan; an octreotide scan was negative. The patient underwent laparotomy and enucleation of a benign tumour, measuring 2.6 cm in diameter, lying within the head of the pancreas; histological examination confirmed it to be an insulinoma. Postoperatively, the patient's personality gradually became more normal and his fasting blood glucose concentrations returned to within normal limits. The diagnosis and management of insulinoma are discussed in the context of this clinical case; there is also reference to the protean clinical manifestations that may occur in this condition- and its differential diagnosis.- - - - - - - - - - ranking = 0.068902441948206keywords = physical (Clic here for more details about this article) |
5/23. A rare cause of syncope in a patient with diabetes mellitus--a case report.INTRODUCTION: Hypoglycaemic episodes in patients with diabetes mellitus are mostly due to excess doses of exogenous insulin or oral hypoglycaemic agents, coupled with poor caloric intake and excessive unplanned physical exertion. Hypoglycaemia as a result of endogenous hyperinsulinaemia due to an insulinoma is extremely rare in such patients. CLINICAL PICTURE: This patient with type 2 diabetes mellitus presented with episodes of syncope. Investigations confirmed recurrent hypoglycaemia from endogenous hyperinsulinaemia, with localisation of a tumour in the tail of the pancreas. TREATMENT: Distal pancreatectomy and splenectomy. histology confirmed an insulinoma. OUTCOME: No further hypoglycaemic episodes were noted. The patient returned to his diabetic state with rather poor glycaemic control. CONCLUSIONS: Repeated hypoglycaemic episodes in a patient with diabetes mellitus despite complete withdrawal of hypoglycaemic agents should lead one to consider other causes of hypoglycaemia.- - - - - - - - - - ranking = 0.068902441948206keywords = physical (Clic here for more details about this article) |
6/23. insulinoma in a patient with tuberous sclerosis: is there an association?OBJECTIVE: To describe a patient with tuberous sclerosis who, on initial assessment, had neurologic symptoms, which were ultimately found to be caused by an insulinoma. methods: We present a case report with clinical, laboratory, and radiologic data. The literature is reviewed relative to tuberous sclerosis and islet cell tumors, and a possible association is discussed. RESULTS: A 43-year-old man with a history of tuberous sclerosis required medical attention because of mental confusion and slurred speech and was found to have hypoglycemia. Neuroradiologic imaging showed no new lesions to account for his symptoms. His physical examination was striking for a large abdominal mass, which showed increased uptake on octreotide scanning. After surgical resection, the mass measured 21 cm and was found to be an insulinoma. blood glucose values were normal postoperatively and on follow-up, and the patient had no recurrence of the symptoms. CONCLUSION: From this report, we emphasize two findings. First, we draw clinicians' attention to the possibility of an association between islet cell tumors and tuberous sclerosis and suggest consideration of this diagnosis in patients with tuberous sclerosis who have new or worsening neurologic symptoms. Second, the insulinoma we describe is, to our knowledge, the largest to be reported thus far in the literature.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
7/23. Macrocystic serous adenoma of the pancreas.Macrocystic serous adenoma of the pancreas (MSAP) is a rare neoplasm. Its preoperative diagnosis by physical examination and imaging studies is challenging, if not impossible. In recent years, a few cases of MSAP with correct cytodiagnosis by transabdominal fine-needle aspiration (TFNA) have been documented. This paper reports two cases of MSAP that were successfully diagnosed by TFNA cytology. Two adult women presented with epigastric discomfort. Abdominal imaging studies revealed a large pancreatic cystic lesion in both cases. TFNAs of the pancreatic lesions were subsequently performed and revealed a clear serous fluid containing small monolayered sheets of benign cuboidal epithelial cells with scant, clear or granular cytoplasm, vesicular nuclei and micronucleoli. The cell cytoplasm stained positively with periodic acid-Schiff (PAS) and negatively with PAS with prior digestion with diastase (PASD). The cytological findings in both cases were similar and suggested a serous cystadenoma. The two pancreatic lesions were removed by Whipple's operation. They showed features of a macrocystic serous adenoma of the pancreas that were characterized by a small number of large cystic cavities lined by a single layer of non-mucus secreting, PAS-positive and PASD-negative cuboidal epithelial cells. By electron microscopy, the epithelial lining cells showed short and aborted apical microvilli, well-formed desmosomes and a large amount of intracytoplasmic glycogen, suggesting a centroacinar ductal cell origin.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
8/23. Solitary pancreatic tuberculous abscess mimicking prancreatic cystadenocarcinoma: a case report.BACKGROUND: The incidence of pancreatic tuberculosis is extremely rare, and it frequently misdiagnosed as pancreatic neoplasms. The nonsurgical diagnosis of this entity continues to be a challenge. CASE PRESENTATION: A 33 year old male with six-month history of intermittent right epigastric vague pain and weight lost had found a solitary pancreatic cystic mass and diagnosed as pancreatic cystadenocarcinoma. The chest x-ray film and physical examination revealed no abnormalities. Abdominal ultrasound (US) examination showed an irregular hypoechoic lesion of 6.6 cm x 4.4 cm in the head of pancreas, and color Doppler flow imaging did not demonstrate blood stream in the mass. The attempts to obtain pathological evidence of the lesion by US-guided percutaneous fine needle aspiration failed, an exploratory laparotomy and incisional biopsy revealed a caseous abscess of the head of pancreas without typical changes of tuberculous granuloma, but acid-fast stain was positive. CONCLUSIONS: Pancreatic tuberculosis should be considered in the differential diagnosis of focal pancreatic lesions, especially for young people in developing countries.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
9/23. Autoimmune pancreatitis presenting as a mass in the head of the pancreas: a diagnosis to differentiate from cancer.We report a case of autoimmune pancreatitis presenting as a mass in the head of the pancreas that was successfully diagnosed without pancreaticoduodenectomy. The patient was a 64-year-old man who had no complaint. A routine physical checkup unexpectedly revealed mild diabetes and a low-echoic mass in the pancreatic head. The diagnosis was made by noting irregular narrowing of the main pancreatic duct, hypergammaglobulinemia, and increased immunoglobulin g levels. An open wedge biopsy of the mass was performed; this showed a marked fibrosis with lymphocyte- or macrophage-predominant inflammatory infiltrates. Immunohistochemical study revealed that the remnant acinar cells expressed Fas (CD95) ligand and not Fas. We review some of the literature and discuss various features and diagnostic clues of autoimmune pancreatitis. awareness of this pathologic condition may prevent confusion with pancreatic malignancy and unnecessary surgery.- - - - - - - - - - ranking = 0.068902441948206keywords = physical (Clic here for more details about this article) |
10/23. Long-term survivor without recurrence after resection of simultaneous solitary pancreatic metastasis from thyroid medullary carcinoma.A 43-year-old Japanese man had an increasing level of serum CEA pointed out by annual physical check-ups. No abnormal findings were detected in the lungs or gastrointestinal tract. The only pathological lesions were a 1.5-cm-sized nodule in the pancreatic tail and a 5-cm-sized thyroid tumor. The thyroid tumor was shown to be medullary carcinoma by aspiration cytology. He underwent total thyroidectomy with extensive lymph node dissection. After thyroid surgery, the patient received distal pancreatectomy 2 weeks later. Pathological examination revealed the pancreatic tumor to be a metastasis of thyroid medullary carcinoma. The patient is alive and well without recurrence 5 years after thyroidectomy and pancreatectomy. The serum levels of CEA and calcitonin remain within normal limits. Thus, the patient seems to have had a solitary metastatic tumor from thyroid medullary cancer.- - - - - - - - - - ranking = 0.068902441948206keywords = physical (Clic here for more details about this article) |
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