Volume 71 - 2008 - Fasc.3 - Case reports
Severe acute cholestatic hepatitis with prolonged cholestasis and bile-duct injury following atorvastatin therapy : a case report
We report the case of a patient who exhibited severe acute hepatitis with symptomatic cholestasis for more than 3 months and bile duct injury following the prescription of atorvastatin. After withdrawal the drug, the patient's wellbeing slowly improves and biological features normalize in 4 months. Therapy aimed at treat- ing severe liver steatosis and hypercholesterolemia. Atorvastatin is a highly effective 3-hydroxy-3 methylglutamyl- coenzyme A reduc- tase (statin) used to lower low-density lipoprotein. Reported frequent adverse events of the medication include nausea, depres- sion, myalgia, abdominal pain and abnormal liver function tests. Although abnormal liver function tests is not an uncommon side effect of the medication, more serious liver injury is rare. In a recent literature review, about ten cases of serious hepatotoxicity have been documented. In the typical presentation, the duration of exposure prior to hepatic toxicity is variable. Liver injury is gener- ally of the mixed type. A prolonged cholestasis for more than 3 months has been seldom reported. Morphological changes includes canalicular cholestasis, feathery degeneration but no cholangiolitis nor cholangitis under the form of cytological and inflammatory changes at the level of interlobular bile ducts. This case report provides further evidence that among statins, atorvastatin may be implicated in drug-induced liver injury and indicates for the first time that such liver injury may be followed by prolonged cholestasis and interlobular bile duct injury. Atorvastatin has thus to be added to the list of medication poten- tially responsible for bile duct injury. (Acta gastroenterol. belg., 2008, 71, 318-320).
Poorly differentiated adenocarcinoma in the ascending colon with peritoneal dissemination : case report of a patient who survived more than eleven years
Poorly differentiated adenocarcinoma of the large bowel is a rare condition known as having a poor prognosis. We report here- in a case of a patient with a poorly differentiated adenocarcinoma in the ascending colon with peritoneal dissemination who survived more than eleven years thanks to adjuvant chemotherapy. A 53- year-old woman with continuous diarrhea was referred to our hos- pital. Physical examination revealed a fist-sized mass in the right lower quadrant. Barium enema study and colonoscopy showed an ascending colon tumor. Abdominal computed tomography showed extensive ascites and masses besides the ascending colon and in the upper abdomen. Laparotomy confirmed dissemination to the peri- toneum, the pouch of Douglas and the omentum. Right hemicolec- tomy was performed and two masses of the omentum were removed in a palliative intent. Twenty mg of mitomicin C were given intraperitoneally. The resected specimen revealed an ulcerat- ed hard mass 5??5cm in size with unclear margin. Histology showed a poorly differentiated adenocarcinoma with dissemination to the omentum. A continuous infusion of 3000 mg of 5-fluorouracil per 48 hours was given weekly for four weeks followed by 450 mg of oral UFT-E (Uracil:Tegafur) per day as post-operative chemotherapy. The postoperative course was uneventful. Although she underwent removal of a breast cancer eight years after the operation for colon cancer, no sign of tumor progression has been observed for 132 months since the initial operation, by taking UFT- E without any adverse events. (Acta gastroenterol. belg., 2008, 71, 321-324).
Concomitant chemo-radiotherapy as standard therapy in limited-stage small-cell oesophageal cancer : A summary of 3 clinical cases and review of the literature
Small-cell carcinoma of the oesophagus (SCCO) is a rare and aggressive malignant tumour associated with a poor prognosis. Between 1994 and 2002, three patients with SCCO were treated in our institution, representing 1.96% (3 out of 153) of all oesophageal malignancies seen during this period. All of these patients had limited-stage SCCO at initial diagnosis and were treated by chemotherapy (cisplatin and etoposide) with concomitant radio- therapy. An initial complete response of the primary lesion was observed in all cases and a persistent complete remission in two of the cases. Chemo-radiotherapy should be considered as a valuable treatment alternative to surgery for limited-stage small-cell carcinoma of the oesophagus. (Acta gastroenterol. belg., 2008, 71, 325-329).
Churg-Strauss syndrome associated with acalculous cholecystitis and liver involvement
We describe a 65-year-old man who had liver involvement with Churg-Strauss syndrome. He was admitted to the hospital because of fever, weight loss, dyspnea, abdominal pain, skin lesions and paraesthesias. His past medical history revealed a diagnosis of acal- culous cholecystitis that had been made eight months earlier. Microscopic examination of a gall bladder biopsy specimen obtained at that time revealed an increase in extravascular eosinophils. There was evidence of a new bilateral pulmonary dis- ease with bronchoconstriction and a transient infiltrated lesion in the right upper lung. The patient's white cell count was 14 620 per cubic millimetre, with 39% eosinophils (5800 per cubic millimetre) and 39% neutrophils. IgE was 503 g/L (normal range, 0 to 100 g/L). Liver function tests were mildly elevated. Fine needle liver biopsy showed active interface hepatitis. A diagnosis of Churg-Strauss syndrome was made. In this patient the syndrome occurred in a rare association with hepatitis, likely due to immuno- logic events in the liver. The patient was successfully treated with 60 mg/day of prednisolone monotherapy. (Acta gastroenterol. belg., 2008, 71, 330-332).
Successful endoscopic ultrasound-guided ethanol ablation of a sporadic insulinoma
Objective : Most insulinomas are benign sporadic tumours that require complete resection to avoid recurrent symptoms of hypo- glycaemia. Alternate minimally invasive therapies are seeked in elderly patients in whom extensive surgery might be life-threaten- ing. We wanted to evaluate the feasibility, safety and efficacy of ethanol injection using endoscopic ultrasound (EUS) guidance to ablate a pancreatic insulinoma.
Patient and methods : A 78-yr-old female patient was referred in our academic medical centre for symptomatic hypoglycaemia. Laboratory and imaging work-up confirmed the diagnosis of an insulinoma presenting as a small tumour located deeply in the pan- creas head, in close vicinity with the Wirsung's duct. Major pan- creatic resection was contra-indicated due to the poor condition of the patient. Endosonography using a linear-array endoscope allowed injection of 3.5 ml of 98% ethanol in the pancreatic tumour after endoprosthetic stenting of the biliary and pancreatic ducts.
Results : There was no recurrence of hypoglycemia, and fasting tests performed 12 days and 3 months after the procedure showed complete remission of endogenous hyperinsulinism. Complications included a mild and asymptomatic elevation of pancreatic enzymes for 2 days and the later occurrence of medically-controlled hematoma and ulceration of the duodenal wall. Complete normal- ization of pancreatic head morphology was confirmed by imaging at 3 months and the patient remains currently asymptomatic and normoglycemic more than two years after the procedure.
Conclusions : EUS-guided ethanol ablation of sporadic insulino- ma is a new feasible and efficient therapy to be considered for small and localized lesions in poor surgical candidates. (Acta gastro- enterol. belg., 2008, 71, 333-337).
Unusual pressure-induced rupture of colonic volvulus in a patient with long-term corticosteroid therapy
Perforation due to colonic volvulus is typically considered to occur following ischemic necrosis of the intestinal wall. In this report, we report a rare case of sigmoid colon volvulus rupture caused by increasing intraluminal pressure without any sign of ischemia. The patient was an 88-year old Japanese male, who had been treated with 5 mg of oral prednisolone daily for 8 years. He consulted for severe abdominal pain that had lasted for three days. X-ray and computed tomography showed free peritoneal air, sug- gesting peritonitis. He was diagnosed with sigmoid colon volvulus perforation and underwent emergency surgery. Pathological exam- ination showed no ischemic necrosis around the perforations in the resected intestine. As a result, we came to believe that the fragility of the colonic wall, caused by the patient's long-term use of corti- costeroid, had lowered the threshold for pressure-induced colonic rupture. (Acta gastroenterol. belg., 2008, 71, 339-341).
Small bowel obstruction caused by intramural hemorrhage secondary to anti- coagulant therapy
Intramural hemorrhage as a cause for small bowel obstruction is extremely rare. We presented an unusual case report of small bowel obstruction caused by intramural jejunal hemorrhage sec- ondary to anticoagulant therapy. An 85-year-old male patient with atrial fibrillation on long-term warfarin presented with nausea and vomiting for 2 days, accompanied with no bowel movement since the onset. Physical exam was unremarkable except soft abdomen with distension but no tenderness, hyperactive bowel sounds and positive fecal occult blood test. Investigations showed anemia with hemoglobin/ hematocrit of 10 (g/dl) / 30%, prothrombin time with an International Normalized Ratio (INR) of 9.58. Abdominal x-ray showed air fluid levels suggestive of small bowel obstruction. Contrast-enhanced abdominal computerized tomography showed circumferential wall thickening, luminal narrowing and partial small bowel obstruction secondary to intramural jejunal hemor- rhage. Patient recovered completely 48 hours after medical treat- ment (nothing per oral, intravenous fluids, nasal gastric tube, Vitamin K, frozen fresh plasma and packed red blood cell transfu- sion). Spontaneous intramural small-bowel hematoma is rare and occurs in patients who receive excessive anticoagulation with war- farin or who have some other risk factors for bleeding. Intramural hematoma most commonly involves the jejunum, followed by the ileum and the duodenum. The spectrum of presentation is wide, from abdominal pain, emesis to gastrointestinal tract hemorrhage. Abdominal CT is the key for diagnosis, with characteristics includ- ing circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction. Early diagnosis is crucial because most patients are treated nonoperatively with a good outcome. (Acta gastroenterol. belg., 2008, 71, 342-344).
