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S26
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
P0055 JAUNDICE – A DIFFERENTIAL DIAGNOSIS DILEMMA
Bruno Arroja, Sheila Ferreira, Miriam Magalhães, Manuela Canhoto, Cláudia Gonçalves, Filipe Silva, Isabel Cotrim, Helena Vasconcelos. Hospital De Santo André, Leiria Jaundice is a common symptom that frequently leads to an interesting diferential diagnosis discussion in the clinical practice. We present a case of a 50-year old woman that worked as a clerk and had an irrelevant past medical record. Her regular medication was alprazolam 0.5 mg. The patient searched hospital medical help complaining of low fever 37.5° – 38°C, malaise, nausea, lost of appetite and abdominal discomfort localized to the right hipocondrium lasting for the previous five days. She also mentioned jaundice, choluria and acholia for the last 48 hours. She denied alcohol or any other drugs consumption, recent travel, contact with jaundiced persons, contact with animals, blood transfusions, surgery. She admitted unprotected sexual relations with her husband. Physical examination revealed jaundice of skin and mucosa, absence of rash, insects bits or palpable lymphadenopathies; Temperature 37.5°C, heart rate 105 ppm, respiratory rate 16 bpm, BP 115/80 mmHG; cardiac and respiratory sounds were normal on auscultation; abdomen was soft and tender with localized pain on the right upper quadrant although without peritoneal reaction. Laboratory data: white blood cells count 9.3×103 /μL with 63% of total being lymphocytes, haemoglobin 13.6 g/dL, platelets 183.000×103 /μL, INR 0.94, AST 256 U/L, ALT 283 U/L, GGT 440 U/L, ALP 627 U/L, total bilirubin 4.2 mg/dL, direct bilirubin 2.8 mg/dL, creatinine 1.4 mg/dL, blood urea nitrogen 17.4 mg/dL, CRP 8.5 mg/dL. Chest X-ray was normal. Abdominal ultrasound showed a normal sized and shaped liver with a heterogeneous parenchyma; absence of common bile duct or intra-hepatic ducts dilatation; absence of gall stones or peritoneal effusion. The patient was admitted at a medical ward with the diagnosis of indeterminate acute cholestatic hepatitis and empirically medicated with ceftriaxone 2g id iv plus doxycyclin 100 mg orally bid. Further investigation was negative for HAV, HBV, HCV, HIV I and II, HSV 1 and 2, CMV, Q fever, Rickettsia conorii, leptospyrosis, brucellosis and tuberculosis. Auto-immune panel was normal as well as blood levels of iron, ferritin and ceruloplasmin. EBV serology came positive. During hospital stay the patient developed pleural effusion with severe hypoalbuminemia (15 g/dL) attributable to the inflammatory condition which resolved with diuretics and IV albumin administration. Liver enzymes and bilirubin persisted elevated although there were significant clinical improvements leading to a discharge at day twelve. Currently the patient has been evaluated as an asymptomatic outpatient and blood analysis have normalized. This case brings to our attention that EBV infection may present as a hepatic cholestatic disease and it is important not to rule it out while considering other diagnostic hypothesis.
pancreatography mechanical lithotripsy basket. Fragments were subsequently removed using baskets and nets. Repeat endoscopy next day showed complete resolution of obstruction and a cholecystoduodenal fistula was identified in first part of duodenum. The patient’s symptoms resolved completely and he was discharged after 48 hours. Discussion & conclusion: This case demonstrates a rare but well documented cause of gastric outlet obstruction. Bouveret’s syndrome often present a diagnostic challenge resulting in delay in appropriate management. Most of the cases in litrature are managed surgically. This case demonstrates that endoscopy is a simple and safe method for treating patients with Bouveret’s syndrome. Surgical enterotomy is an option reserved for patients with failed endoscopic therapy and fit for operation. Keywords: Bouveret’s syndrome, Gastric outlet obstruction, gallstone ileus, cholecystoduodenal fistula
P0057 AORTODUODENAL FISTULA: A RARE CAUSE OF GASTROINTESTINAL BLEEDING
Dulce Alfaiate, Cláudia Silva, Rita Mendes, Paula Augusto, Raquel Nazareth, Mónica Levy, Gonçalo Luz, Carlos Nascimento, Francisco Silva, José Pimenta-da-Graça. Hospital De Egas Moniz - Chlo, Epe Introduction: Primary aortoenteric fistula is a rare cause of massive gastrointestinal hemorrhage, usually due to the rupture of an abdominal aortic aneurism into the intestinal tract (most common sites being the third and fourth portions of the duodenum – 88%), and has a high mortality (in some series greater than 60%). Objectives: We intend to alert to the importance of this entity as a rare cause of serious gastrointestinal bleeding. Materials & methods: The authors report the case of a 73-year-old man admitted to an Internal Medicine ward with hematemesis. Results: The patient had a prior history of gastric ulcer and a pyloroplasty and truncal vagotomy that had been done 7 years before. Following admission, he had serveral episodes of massive gastrointestinal bleeding, needing frequent blood transfusions. Esophagogastroduodenal endoscopy (performed at the time of admission and repeated posteriorly) and abdominal ultrassound failed to localize the sourse of bleeding. The patient had a catastrophic bleeding episode complicated by hypovolemic shock and he was brought emergently to the operating room where the diagnosis of aortoduodenal fistula was made. After surgical correction, he initially recovered, but later developed a enterocutaneous fistula complicated by septic shock and died, two months after surgery. Discussion & conclusion: We report this case as an example of a rare etiology for gastrointestinal bleeding. It should be considered in any patient with major bleeding, with no identifiable cause in endoscopic examinations, even when there is a more probable cause for the bleeding (as was the case of this patient with prior peptic disease).
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P0058
LEAVE NO STONE UNTURNED
AUTOIMMUNE DISEASES ASSOCIATED TO AUTOIMMUNE HEPATITIS: A RETROSPECTIVE STUDY OF 16 PATIENTS IN TUNISIA
Salahudin Khalid 1 , Howard Smart 2 , Anthony Morris 2 . 1 Warrington General Hospital; 2 Royal Liverpool University Hospital Introduction: We present a very interesting case of a patient presenting with gastric outlet obstruction. He was diagnosed with Bouveret’s syndrome and successfully managed endoscopically. Bouveret’s syndrome, initially described by Bouveret in 1896, is a rare but well documented cause of gastric outlet obstruction. It is caused by a large gallstone impacted in the pyloric canal or more commonly the duodenum. The stone usually enters the duodenum via a cholicystoduodenal fistula. The commonest site of gall stone impaction is terminal ileum followed by duodenum and stomach. It is most common in elderly females, mean age 70 years, with history of symptomatic biliary disease. Results: We present a case of a 95 years old man who presented with 24 hours history of epigastric pain and vomiting. He had multiple co morbidities including previous stroke, myocardial infarction, renal failure, severe diverticular disease, diabetes, hypothyroidism and anaemia. Examination revealed only epigastric fullness and tenderness. Abdominal film was consistent with gastric outlet obstruction (See Image). Endoscopy identified a large (4 cm) stone of gall bladder origin causing complete obstruction at the level of duodenal bulb (See Image). An urgent CT scan was organised (See Image) and a therapeutic endoscopy was performed next day under sedation. The stone was fragmented using an adapted endoscopic retrograde cholangio
Elhem Benjazia, Mabrouk Khalifa, Amor Alaoua, Nairouz Ghannouchi, Wissem Hachfi, Naoufel Kaabia, Ahlem Brahem, Amel Letaief, Fethi Bahri. Department of Internal Medicine and Infectious Diseases. University Hospital F.hached, Sousse, Tunisia Introduction: Autoimmune hepatitis (AIH) is a chronic liver disease of unknown aetiology, with diverse clinical manifestations; despite its strong association with autoimmunity, AIH is still an idiopathic disease that does not have a specific target antigen for most available autoantibodies. Autoimmune extra-hepatic manifestations are associated in 15- 50% of patients. Objectives: The aim of this study was to determine the prevalence and the type of autoimmune extra-hepatic manifestations associated to the AIH Materials & methods: We retrospectively reviewed the medical records of 16 patients who were followed for AIH at the Infectious disease and Internal medicine unit from January 2000 to January 2008. All patients satisfied the revised criteria of the International Autoimmune Hepatitis group (IAIHG) for the diagnosis of AIH. Auto-immune diseases were looked out by clinical and biological tests in all patients. Results: Sixteen patients were studied: (15 women, 1 man), the mean age was 39 years (17-65 y). Seven patients (43.7%) had coexisting autoimmune diseases, most frequently pathology was: hypothyroidism (n: 3), Sjögren’s syndrome (n: 4), Addison disease (n: 1), systemic sclerosis (n: 1) and type
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
P0055 JAUNDICE – A DIFFERENTIAL DIAGNOSIS DILEMMA
Bruno Arroja, Sheila Ferreira, Miriam Magalhães, Manuela Canhoto, Cláudia Gonçalves, Filipe Silva, Isabel Cotrim, Helena Vasconcelos. Hospital De Santo André, Leiria Jaundice is a common symptom that frequently leads to an interesting diferential diagnosis discussion in the clinical practice. We present a case of a 50-year old woman that worked as a clerk and had an irrelevant past medical record. Her regular medication was alprazolam 0.5 mg. The patient searched hospital medical help complaining of low fever 37.5° – 38°C, malaise, nausea, lost of appetite and abdominal discomfort localized to the right hipocondrium lasting for the previous five days. She also mentioned jaundice, choluria and acholia for the last 48 hours. She denied alcohol or any other drugs consumption, recent travel, contact with jaundiced persons, contact with animals, blood transfusions, surgery. She admitted unprotected sexual relations with her husband. Physical examination revealed jaundice of skin and mucosa, absence of rash, insects bits or palpable lymphadenopathies; Temperature 37.5°C, heart rate 105 ppm, respiratory rate 16 bpm, BP 115/80 mmHG; cardiac and respiratory sounds were normal on auscultation; abdomen was soft and tender with localized pain on the right upper quadrant although without peritoneal reaction. Laboratory data: white blood cells count 9.3×103 /μL with 63% of total being lymphocytes, haemoglobin 13.6 g/dL, platelets 183.000×103 /μL, INR 0.94, AST 256 U/L, ALT 283 U/L, GGT 440 U/L, ALP 627 U/L, total bilirubin 4.2 mg/dL, direct bilirubin 2.8 mg/dL, creatinine 1.4 mg/dL, blood urea nitrogen 17.4 mg/dL, CRP 8.5 mg/dL. Chest X-ray was normal. Abdominal ultrasound showed a normal sized and shaped liver with a heterogeneous parenchyma; absence of common bile duct or intra-hepatic ducts dilatation; absence of gall stones or peritoneal effusion. The patient was admitted at a medical ward with the diagnosis of indeterminate acute cholestatic hepatitis and empirically medicated with ceftriaxone 2g id iv plus doxycyclin 100 mg orally bid. Further investigation was negative for HAV, HBV, HCV, HIV I and II, HSV 1 and 2, CMV, Q fever, Rickettsia conorii, leptospyrosis, brucellosis and tuberculosis. Auto-immune panel was normal as well as blood levels of iron, ferritin and ceruloplasmin. EBV serology came positive. During hospital stay the patient developed pleural effusion with severe hypoalbuminemia (15 g/dL) attributable to the inflammatory condition which resolved with diuretics and IV albumin administration. Liver enzymes and bilirubin persisted elevated although there were significant clinical improvements leading to a discharge at day twelve. Currently the patient has been evaluated as an asymptomatic outpatient and blood analysis have normalized. This case brings to our attention that EBV infection may present as a hepatic cholestatic disease and it is important not to rule it out while considering other diagnostic hypothesis.
pancreatography mechanical lithotripsy basket. Fragments were subsequently removed using baskets and nets. Repeat endoscopy next day showed complete resolution of obstruction and a cholecystoduodenal fistula was identified in first part of duodenum. The patient’s symptoms resolved completely and he was discharged after 48 hours. Discussion & conclusion: This case demonstrates a rare but well documented cause of gastric outlet obstruction. Bouveret’s syndrome often present a diagnostic challenge resulting in delay in appropriate management. Most of the cases in litrature are managed surgically. This case demonstrates that endoscopy is a simple and safe method for treating patients with Bouveret’s syndrome. Surgical enterotomy is an option reserved for patients with failed endoscopic therapy and fit for operation. Keywords: Bouveret’s syndrome, Gastric outlet obstruction, gallstone ileus, cholecystoduodenal fistula
P0057 AORTODUODENAL FISTULA: A RARE CAUSE OF GASTROINTESTINAL BLEEDING
Dulce Alfaiate, Cláudia Silva, Rita Mendes, Paula Augusto, Raquel Nazareth, Mónica Levy, Gonçalo Luz, Carlos Nascimento, Francisco Silva, José Pimenta-da-Graça. Hospital De Egas Moniz - Chlo, Epe Introduction: Primary aortoenteric fistula is a rare cause of massive gastrointestinal hemorrhage, usually due to the rupture of an abdominal aortic aneurism into the intestinal tract (most common sites being the third and fourth portions of the duodenum – 88%), and has a high mortality (in some series greater than 60%). Objectives: We intend to alert to the importance of this entity as a rare cause of serious gastrointestinal bleeding. Materials & methods: The authors report the case of a 73-year-old man admitted to an Internal Medicine ward with hematemesis. Results: The patient had a prior history of gastric ulcer and a pyloroplasty and truncal vagotomy that had been done 7 years before. Following admission, he had serveral episodes of massive gastrointestinal bleeding, needing frequent blood transfusions. Esophagogastroduodenal endoscopy (performed at the time of admission and repeated posteriorly) and abdominal ultrassound failed to localize the sourse of bleeding. The patient had a catastrophic bleeding episode complicated by hypovolemic shock and he was brought emergently to the operating room where the diagnosis of aortoduodenal fistula was made. After surgical correction, he initially recovered, but later developed a enterocutaneous fistula complicated by septic shock and died, two months after surgery. Discussion & conclusion: We report this case as an example of a rare etiology for gastrointestinal bleeding. It should be considered in any patient with major bleeding, with no identifiable cause in endoscopic examinations, even when there is a more probable cause for the bleeding (as was the case of this patient with prior peptic disease).
P0056
P0058
LEAVE NO STONE UNTURNED
AUTOIMMUNE DISEASES ASSOCIATED TO AUTOIMMUNE HEPATITIS: A RETROSPECTIVE STUDY OF 16 PATIENTS IN TUNISIA
Salahudin Khalid 1 , Howard Smart 2 , Anthony Morris 2 . 1 Warrington General Hospital; 2 Royal Liverpool University Hospital Introduction: We present a very interesting case of a patient presenting with gastric outlet obstruction. He was diagnosed with Bouveret’s syndrome and successfully managed endoscopically. Bouveret’s syndrome, initially described by Bouveret in 1896, is a rare but well documented cause of gastric outlet obstruction. It is caused by a large gallstone impacted in the pyloric canal or more commonly the duodenum. The stone usually enters the duodenum via a cholicystoduodenal fistula. The commonest site of gall stone impaction is terminal ileum followed by duodenum and stomach. It is most common in elderly females, mean age 70 years, with history of symptomatic biliary disease. Results: We present a case of a 95 years old man who presented with 24 hours history of epigastric pain and vomiting. He had multiple co morbidities including previous stroke, myocardial infarction, renal failure, severe diverticular disease, diabetes, hypothyroidism and anaemia. Examination revealed only epigastric fullness and tenderness. Abdominal film was consistent with gastric outlet obstruction (See Image). Endoscopy identified a large (4 cm) stone of gall bladder origin causing complete obstruction at the level of duodenal bulb (See Image). An urgent CT scan was organised (See Image) and a therapeutic endoscopy was performed next day under sedation. The stone was fragmented using an adapted endoscopic retrograde cholangio
Elhem Benjazia, Mabrouk Khalifa, Amor Alaoua, Nairouz Ghannouchi, Wissem Hachfi, Naoufel Kaabia, Ahlem Brahem, Amel Letaief, Fethi Bahri. Department of Internal Medicine and Infectious Diseases. University Hospital F.hached, Sousse, Tunisia Introduction: Autoimmune hepatitis (AIH) is a chronic liver disease of unknown aetiology, with diverse clinical manifestations; despite its strong association with autoimmunity, AIH is still an idiopathic disease that does not have a specific target antigen for most available autoantibodies. Autoimmune extra-hepatic manifestations are associated in 15- 50% of patients. Objectives: The aim of this study was to determine the prevalence and the type of autoimmune extra-hepatic manifestations associated to the AIH Materials & methods: We retrospectively reviewed the medical records of 16 patients who were followed for AIH at the Infectious disease and Internal medicine unit from January 2000 to January 2008. All patients satisfied the revised criteria of the International Autoimmune Hepatitis group (IAIHG) for the diagnosis of AIH. Auto-immune diseases were looked out by clinical and biological tests in all patients. Results: Sixteen patients were studied: (15 women, 1 man), the mean age was 39 years (17-65 y). Seven patients (43.7%) had coexisting autoimmune diseases, most frequently pathology was: hypothyroidism (n: 3), Sjögren’s syndrome (n: 4), Addison disease (n: 1), systemic sclerosis (n: 1) and type