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P0066 THERAPEUTIC PLASMA EXCHANGE IN THE TREATMENT OF ACUTE PANCREATITIS DUE TO HYPERTRIGLYCERIDEMIA
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
S29
P0064 RECURRENT CHOLANGITIS AND PANCREATITIS DUE TO RUPTURE OF A HYDATID CYST TO THE BILIARY TREE
Olga Giouleme, Eleni Tsiaousi, Niki Katsiki, Athena Myrou, Maria Masmanidou, Dimitrios Koliouskas. 1st Propedeutic Department of Internal Medicine, Ahepa University Hospital, Thessaloniki, Greece Aim: To present a case of recurrent cholangitis and pancreatitis due to rupture of a hydatid cyst to the biliary tree. Patient, methods and results: A 51 year old male from Eastern Europe presented with diffuse abdominal pain and vomiting for the last 24 hours and fever with malaise during the past three weeks. Laboratory findings indicated cholangitis, accompanied by pancreatitis: AST 65 U/l; ALT 151 U/l; GGT 1274 U/l; ALP 501 U/l; total bilirubin 12,24 mg/dl (3,2 mg/dl direct); WBC 12240/μL; serum amylase 1099 U/l. Ultrasound and Computed Tomography of the abdomen revealed a cystic mass measuring 12,7×10,4×12 cm in the right hepatic lobe, resembling a hydatid cyst. The MRCP and MRI of the abdomen confirmed the diagnosis of a hydatid cyst, also containing a daughter cyst. The cyst communicated with the biliary tree which contained material from the ruptured cyst1. Serology confirmed the diagnosis. The ELISA test detected IgG (18+) and IgM (2+) specific for echinococcus granulosus2. Fifteen days later, the patient presented with identical symptoms and laboratory findings. Intrabiliary rupture of the hydatid cyst and a consequent obstruction of the biliary tree had recurred. Symptoms subsided quickly. Conclusion: This was an unusual case of recurrent cholangitis and pancreatitis due to intrabiliary rupture of a hydatid cyst. The patient was finally scheduled for ERCP for biliary drainage2 and also for surgical removal of the cyst. Preoperatively he was introduced to albendazole for three months, with 15 days’ interval each month. References: 1. Tsitouridis J, Kouklakis G, Tsitouridis K, Melidis D, Krokos N, Emmanouilidou M. Intrabiliary obstruction due to ruptured hydatid cyst: Evaluation with computed tomography and magnetic resonance imaging. Digestive Endoscopy 2001;13:7-12. 2. Giouleme O, Nikolaidis N, Zezos P, Budas K, Katsinelos P, Vasiliadis T, Eugenidis N. Treatment of complications of hepatic hydatid disease by ERCP. Gastrointest Endosc 2001; 54(4):508-510.
P0065 REFRACTORY ASCITIS
Ussumane Embalo, Sergio Silva, Svetelana Mikhailovna, Fernando Friões, Jorge Almeida. Hospital De São João,porto, Portugal A 36-year-old woman with biopsy-confirmed hepatic cirrhosis (secondary to excessive and continuing alcohol consumption), portal hypertension, esophageal varices, splenomegaly and recurrent large-volume ascites (currently managed by monthly paracentesis) was admitted for placement of a transjugular intrahepatic portosystemic shunt (TIPS). The procedure was complicated by an arterio-portal fistula which was successfully embolized. Post-TIPS she complained of abdominal pain and an abdominal CT (Computer tomography) scan showed small-volume ascites and a tense fluid collection, with a transverse diameter of 25 cm and thickened contrast-enhancing walls, extending from the epiploic retrocavity to the pelvis. Transvaginal ultrasound showed a normal uterus and right ovary. The left ovary could not be visualized, and an ovarian origin for the cyst was postulated. At laparotomy the cyst was found to be adherent to the pancreas. Final diagnosis
Figure 3. Surgical piece.
was pancreatic pseudocyst with aspiration of more than 10 L of yellowish fluid.
P0066 THERAPEUTIC PLASMA EXCHANGE IN THE TREATMENT OF ACUTE PANCREATITIS DUE TO HYPERTRIGLYCERIDEMIA
Gurhan Kadikoylu 1 , Vahit Yukselen 2 , Irfan Yavasoglu 1 , A. Onder Karaoglu 2 , Zahit Bolaman 1 . 1 Adnan Menderes University Medical Faculty, Division of Hematology, Aydin, Turkey; 2 Adnan Menderes University Medical Faculty, Division of Gastroenterology, Aydin, Turkey Three percent of acute pancreatitis is due to hypertriglyceridemia. The risk of acute pancreatitis is very high when triglyceride levels exceed 1000 mg/dl. Case 1: Thirty-three years old male was admitted to our hospital, because of severe abdominal pain and vomiting for one day. He has received irregular triglyceride-lowering treatment. On physical examination, arterial blood pressure was 130/90 mmHg, pulse rate 105/min, blood temperature 37.8 0C. Tenderness on epigastria region and rebound tenderness on all abdomen were detected. Laboratory values were white blood cell count 23.000/mm3 , CRP 148 mg/L, ALT 72 IU/L, LDH 586 IU/L, amylase 4234 IU/L, lipase 606 IU/L, triglyceride 4408 mg/dl, and total cholesterol 765 mg/dl. Stage-E acute pancreatitis was diagnosed to the patient according to Balthazar classification on abdominal computed tomography. The patient was treated with serum saline, imipenem, and discontinuation of oral hydration. Two times therapeutic plasma exchange (TPD) was performed. The levels of amylase and triglyceride levels decreased to 76 IU/L and 320 mg/dL, respectively after two courses TPD. At 7th day, abdominal pain and vomiting improved. Case 2: Twenty-eight years old male was admitted to our hospital, because of severe continued abdominal pain unresponsive to analgesics. He suffered from acute pancreatitis four years ago. On physical examination, arterial blood pressure was 105/60 mmHg, pulse rate 88/min, blood temperature 38,5 0C. Rebound tenderness on epigastria region was detected. Laboratory values were white blood cell count 12.400/mm3 , CRP 66.9 mg/L, amylase 1618 IU/L, and triglyceride 2210 mg/dl. Stage-D acute pancreatitis was diagnosed to the patient according to Balthazar classification on abdominal computed tomography. The patient was treated with serum saline, ceftriakson, and discontinuation of oral hydration. One time therapeutic plasma exchange (TPD) was performed. The levels of amylase and triglyceride levels decreased to 107 IU/L and 154 mg/dL, respectively. After 8 days, fever and abdominal pain were lost. In conclusion, TPD may be used as adjunctive therapy to primary treatment in the treatment of acute pancreatitis due to hypertriglyceridemia. Key words: Acute pancreatitis, hypertriglyceridemia, plasma exchange
P0067 CELIAC SPRUE
Antonio Eduardo Leal Antunes, João Santos. Hospital Santo André
Figure 1. Patient with ascitis.
Figure 2. Abdominal cyst on TC scan
Introduction: Celiac sprue, malabsorption disorder characterized by abnormal small-bowel structure and intolerance to gluten, a protein found in wheat and wheat products.A peak incidence in the third and fourth decades of live with a female preponderance.Celiac sprue patient have an increased frequency of the HLA-DR3 type, wich is present in 70 to 90% of sprue patient. The authors present a clinical case of a 29 year old female that came to the outpatient clinic with the following complaints: edema of the lower limbs, polydipsia, weight loss, diarrhea (clay-colored; four to five times a day and > 300 g of loose stool), abdominal distention and bloating. The past family, personal and social history is irrelevant. No drug allergy was noted. The
S29
P0064 RECURRENT CHOLANGITIS AND PANCREATITIS DUE TO RUPTURE OF A HYDATID CYST TO THE BILIARY TREE
Olga Giouleme, Eleni Tsiaousi, Niki Katsiki, Athena Myrou, Maria Masmanidou, Dimitrios Koliouskas. 1st Propedeutic Department of Internal Medicine, Ahepa University Hospital, Thessaloniki, Greece Aim: To present a case of recurrent cholangitis and pancreatitis due to rupture of a hydatid cyst to the biliary tree. Patient, methods and results: A 51 year old male from Eastern Europe presented with diffuse abdominal pain and vomiting for the last 24 hours and fever with malaise during the past three weeks. Laboratory findings indicated cholangitis, accompanied by pancreatitis: AST 65 U/l; ALT 151 U/l; GGT 1274 U/l; ALP 501 U/l; total bilirubin 12,24 mg/dl (3,2 mg/dl direct); WBC 12240/μL; serum amylase 1099 U/l. Ultrasound and Computed Tomography of the abdomen revealed a cystic mass measuring 12,7×10,4×12 cm in the right hepatic lobe, resembling a hydatid cyst. The MRCP and MRI of the abdomen confirmed the diagnosis of a hydatid cyst, also containing a daughter cyst. The cyst communicated with the biliary tree which contained material from the ruptured cyst1. Serology confirmed the diagnosis. The ELISA test detected IgG (18+) and IgM (2+) specific for echinococcus granulosus2. Fifteen days later, the patient presented with identical symptoms and laboratory findings. Intrabiliary rupture of the hydatid cyst and a consequent obstruction of the biliary tree had recurred. Symptoms subsided quickly. Conclusion: This was an unusual case of recurrent cholangitis and pancreatitis due to intrabiliary rupture of a hydatid cyst. The patient was finally scheduled for ERCP for biliary drainage2 and also for surgical removal of the cyst. Preoperatively he was introduced to albendazole for three months, with 15 days’ interval each month. References: 1. Tsitouridis J, Kouklakis G, Tsitouridis K, Melidis D, Krokos N, Emmanouilidou M. Intrabiliary obstruction due to ruptured hydatid cyst: Evaluation with computed tomography and magnetic resonance imaging. Digestive Endoscopy 2001;13:7-12. 2. Giouleme O, Nikolaidis N, Zezos P, Budas K, Katsinelos P, Vasiliadis T, Eugenidis N. Treatment of complications of hepatic hydatid disease by ERCP. Gastrointest Endosc 2001; 54(4):508-510.
P0065 REFRACTORY ASCITIS
Ussumane Embalo, Sergio Silva, Svetelana Mikhailovna, Fernando Friões, Jorge Almeida. Hospital De São João,porto, Portugal A 36-year-old woman with biopsy-confirmed hepatic cirrhosis (secondary to excessive and continuing alcohol consumption), portal hypertension, esophageal varices, splenomegaly and recurrent large-volume ascites (currently managed by monthly paracentesis) was admitted for placement of a transjugular intrahepatic portosystemic shunt (TIPS). The procedure was complicated by an arterio-portal fistula which was successfully embolized. Post-TIPS she complained of abdominal pain and an abdominal CT (Computer tomography) scan showed small-volume ascites and a tense fluid collection, with a transverse diameter of 25 cm and thickened contrast-enhancing walls, extending from the epiploic retrocavity to the pelvis. Transvaginal ultrasound showed a normal uterus and right ovary. The left ovary could not be visualized, and an ovarian origin for the cyst was postulated. At laparotomy the cyst was found to be adherent to the pancreas. Final diagnosis
Figure 3. Surgical piece.
was pancreatic pseudocyst with aspiration of more than 10 L of yellowish fluid.
P0066 THERAPEUTIC PLASMA EXCHANGE IN THE TREATMENT OF ACUTE PANCREATITIS DUE TO HYPERTRIGLYCERIDEMIA
Gurhan Kadikoylu 1 , Vahit Yukselen 2 , Irfan Yavasoglu 1 , A. Onder Karaoglu 2 , Zahit Bolaman 1 . 1 Adnan Menderes University Medical Faculty, Division of Hematology, Aydin, Turkey; 2 Adnan Menderes University Medical Faculty, Division of Gastroenterology, Aydin, Turkey Three percent of acute pancreatitis is due to hypertriglyceridemia. The risk of acute pancreatitis is very high when triglyceride levels exceed 1000 mg/dl. Case 1: Thirty-three years old male was admitted to our hospital, because of severe abdominal pain and vomiting for one day. He has received irregular triglyceride-lowering treatment. On physical examination, arterial blood pressure was 130/90 mmHg, pulse rate 105/min, blood temperature 37.8 0C. Tenderness on epigastria region and rebound tenderness on all abdomen were detected. Laboratory values were white blood cell count 23.000/mm3 , CRP 148 mg/L, ALT 72 IU/L, LDH 586 IU/L, amylase 4234 IU/L, lipase 606 IU/L, triglyceride 4408 mg/dl, and total cholesterol 765 mg/dl. Stage-E acute pancreatitis was diagnosed to the patient according to Balthazar classification on abdominal computed tomography. The patient was treated with serum saline, imipenem, and discontinuation of oral hydration. Two times therapeutic plasma exchange (TPD) was performed. The levels of amylase and triglyceride levels decreased to 76 IU/L and 320 mg/dL, respectively after two courses TPD. At 7th day, abdominal pain and vomiting improved. Case 2: Twenty-eight years old male was admitted to our hospital, because of severe continued abdominal pain unresponsive to analgesics. He suffered from acute pancreatitis four years ago. On physical examination, arterial blood pressure was 105/60 mmHg, pulse rate 88/min, blood temperature 38,5 0C. Rebound tenderness on epigastria region was detected. Laboratory values were white blood cell count 12.400/mm3 , CRP 66.9 mg/L, amylase 1618 IU/L, and triglyceride 2210 mg/dl. Stage-D acute pancreatitis was diagnosed to the patient according to Balthazar classification on abdominal computed tomography. The patient was treated with serum saline, ceftriakson, and discontinuation of oral hydration. One time therapeutic plasma exchange (TPD) was performed. The levels of amylase and triglyceride levels decreased to 107 IU/L and 154 mg/dL, respectively. After 8 days, fever and abdominal pain were lost. In conclusion, TPD may be used as adjunctive therapy to primary treatment in the treatment of acute pancreatitis due to hypertriglyceridemia. Key words: Acute pancreatitis, hypertriglyceridemia, plasma exchange
P0067 CELIAC SPRUE
Antonio Eduardo Leal Antunes, João Santos. Hospital Santo André
Figure 1. Patient with ascitis.
Figure 2. Abdominal cyst on TC scan
Introduction: Celiac sprue, malabsorption disorder characterized by abnormal small-bowel structure and intolerance to gluten, a protein found in wheat and wheat products.A peak incidence in the third and fourth decades of live with a female preponderance.Celiac sprue patient have an increased frequency of the HLA-DR3 type, wich is present in 70 to 90% of sprue patient. The authors present a clinical case of a 29 year old female that came to the outpatient clinic with the following complaints: edema of the lower limbs, polydipsia, weight loss, diarrhea (clay-colored; four to five times a day and > 300 g of loose stool), abdominal distention and bloating. The past family, personal and social history is irrelevant. No drug allergy was noted. The