Volume 82 - 2019 - Fasc.3 - Clinical images
Fatal anaphylaxis of ranitidine injection : have we not learnt the lesson yet?
A 75-year-old man was admitted with complaints of fever and right upper quadrant pain for one day. He underwent a cholecystectomy three month ago. His conscious level was clear (Glasgow Coma Scale or GCS of E4V5M6) with temperature of 38.1 degree Celsius. His blood pressure was 107/53mmHg and pulse rate was 78 bpm. Physical examination showed tenderness without a rebounding pain over his right upper abdomen. His laboratory studies revealed leukocytosis with neutrophils predominant (WBC:11.79 103/uL, Neutrophil: 86.3%) and impaired liver function (AST:476 IU/L; ALT: 332 IU/L) with hyperbilirubinemia mainly of direct type (D-bilirubin:1.7 mg/dL; T-Bilirubin: 3.0 mg/dL). Neither elevation of cardiac enzymes (CPK:81IU/L, CKMB:1.73ng/mL, Troponin I<0.16ng/mL) nor ST changes in electrocardiogram was found. Under a provisional diagnosis of acute cholangitis, he was started on cefoxitin eight hours earlier before admission to ward which was uneventful. Intravenous ranitidine was given at ward for prophylaxis of stress ulcer, although the risk for gastrointestinal bleeding in this patient was not high. Just within minutes after the injection of one ample of ranitidine (Zantac (Getway), 50mg/2ml/amp) in slow push mode (within 10 seconds), patient complained about itchiness all over his body with facial redness. He started to have shortness of breath and cold sweating. Shortly after his conscious levels deteriorated (GCS: E1V2M1) followed by cardio-respiratory collapse. In addition to endotracheal intubation and cardiopulmonary cerebral resuscitation (CPCR) for his cardiorespiratory collapse, adequate doses of hydrocortisone and anti-histamine were given. However, patient did not survive the CPCR and expired 30 mins later. His blood culture yielded E. Coli which was compatible with the initial diagnosis of acute cholangitis. Based on his previous medical record, he did not have any atopic predisposition or drug allergy history. He was ever given with intravenous proton pump inhibitor during cholecystectomy one and a half year ago without a record of allergy.
Metastases until proven otherwise
A 65-year old woman was under hepatologic follow up for nonalcoholic steatohepatitis. She had impaired glucose tolerance with hyperinsulinism, dyslipidemia, visceral fat accumulation with BMI of 25,5 kg/m2 and arterial hypertension. Biopsy in 2011 showed macro- and microvesicular steatisis and mild siderosis, with a NAS score of 4. There was slight perisinusoidal fibrosis with score F1A.
In 2017 she was diagnosed with ductal mammacarci- noma treated with tumorectomy and adjuvant radiotherapy. Ultrasound of the liver on routine hepatologic follow up 6 months later showed a heterogeneous parenchyma and an irregular surface. Shear-wave elastography values were high (mean 18,6 kPa), in accordance with cirrhosis (Fig 1A). Transaminases were mildly elevated with AST 37 IU/L (<31IU/L) and ALT 40 IU/L (<34IU/L), as was gamma-GT of 66 IU/L (<40 IU/L). Alkaline phosphatase, bilirubin and INR were normal. Viral and auto-immune serology was negative. MRI showed a slightly enlarged liver with pseudocirrhosis due to miliary opacities, with innumerable lesions of variable size
A rare cause of colic polyp in a patient with ischemic colitis
A 50-year-old woman was admitted for a rectal bleeding after an episode of defecation 2 days prior to her admission. The patient had also suffered from lower abdominal pain for 3 days, but did not complain about any other pain.
The patient had no personal or familial medical history.
The clinical examination only revealed a sensitive abdomen in the left inferior quadrant of the abdomen without defence or rebound. The vital parameters were normal.
The blood sample showed the following: haemoglobin 15.2 g/dL (12-16), MCV 105 (85-95), leucocytes 11800/ mm3 (4200-9000) among which 8470/mm3 neutrophils (1900-7000), platelets 225000/mm3 (150000-400000) and CRP 171.5 mg/dL (< 12). We noticed that the haemoglobin had decreased from 15.2 g/dL to 11.6 g/ dL between the emergency and our gastroenterological department.
Unexpected newborns in the liver : hemangiomatosis onset after hepatic resection of a giant cavernous hemangioma
A 47-year old woman underwent liver magnetic resonance imaging (MRI). In 2002, during abdominal ultrasound (US), a 4-cm lesion in liver segment VII typical for hemangioma was incidentally discovered. The lesion did not show any dimensional or morphological changes until 2007. The woman had two pregnancies, in 2008 and 2010 and she was not followed up.
In 2011, the woman underwent US due to the onset of abdominal discomfort, and the hemangioma was seen to be notably increased in size (13 cm). This diagnosis was confirmed by liver MRI performed in 2012 (Fig. 1A). In 2013, the patient underwent surgical resection of the hepatic hemangioma which, due to its large dimensions, was probably responsible for the abdominal pain that disappeared after surgery.
