CASE 142: MULTIFOCAL LIVER and VOMITTING at POST PRANDIAL, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

MAN 59 yo,  EPIGATRIC PAIN AND VOMITTING  HAVING MEAL.

ULTRASOUND SCAN OF LIVER DETECTED MANY FOCAL LESIONS WHICH HAD  DIFFERENT ECHOSTRUCTURES : SOLID  HYPERECHOIC, HYPOECHOIC AND CYSTIC, with SIZE  IN AVERAGE OF 1-2 CM OVER THE LIVER.

  

  

THIS PATIENT HAD NO HISTORY OF INFECTED HBV OR HCV, BLOOD TESTS SHOWED    RAISING OF WBC  WITH PLATELET COUNTS IN  HIGH VALUE.

This case based on ultrasound images and one sonologist suggested that was to be microabscesses of liver due to parasites, but blood tests ruling out.

For making clear the symptom of vomitting, an esophago-gastric x-ray was done, and it suggested that a cancer of middle portion of esophagus.
Biopsy confirmed a squamous cell carcinoma of esophagus, causing multifocal nodule metastasis in liver.

  

Do you thing this liver images by ultrasound are metastasis from the esophagus cancer ?.

What is the most different diagnosis for this case ?

Ref. 2 PDF.

CASE 141: RUPTURE of DUODENUM, Dr PHAN THANH HẢI-Dr LÊ TỰ PHÚC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Female patient 19 yo, pain at epigastric area after jumping across a bar in gymnastic activities for 3 hours before admission in Medic Center. She looks pale, and could not keep body straight in walking, and feeling pain when compressing her bossom. Blood pressure: 100/70 mmHg, pulse rate:78 beats/min.

 

 

 

Ultrasound detects edema of wall of D2 and D3 of duodenum, thickening of 16-18mm. There is a discontinuity of serosa of D2 (arrow) which suggests of rupture of D2 . A small amount of fluid around D2 and no free air into abdominal cavity.

 

MDCT 64 discloses thickening of duodenum wall of D2 and D3 and free fluid around duodenum, without free air in peritoneal sac.  Head of pancreas is not well-limted and  catching the contrast unhomogenously.  Suspection of hematoma of duodenum and head of pancreas due to trauma are noted down.

In emergency department of Binh dan Hospital, this case is undergoing by continuous gastric aspiration through nasogastric tube. Clinical status is in very good response, pain reduction, epigastric area no rebound tenderness. After 48 hours,  gastric tube is removed, and she can drink water.

Wait for abdominal CT evaluation of conservative attempting.

CASE 140: LEFT ATRIUM HEMANGIOMA, Dr NGUYỄN KIM THÁI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 58-year–old female with persistent cough for 2 weeks was admitted to MEDIC center for general check up .

The chest X-ray film showed heart slightly enlarged, left heart border bulging on mid zone with a convex shadow about 4cm in diameter (Fig.1). A transthoracic and transesophageal echocardiogram showed a 4x5cm mass, located beside left atrium, at the junction of pulmonary artery and left atrial appendage. No pericardial effusion. (Fig.2,3&4).

 

ECG was within normal limit.The tumor displayed weak contrast on chest computed tomogaphy (Fig.5&6).

 

 

Preoperative diagnosis was pericardial tumor.

The patient underwent uneventful surgery. The tumor was at the lateral wall of left atrium, red brown in color, 4x4cm in diameter (Fig.7).

 

 

 Pathological examination showed  cavernous hemangioma (Fig.8) .

CASE 139: COLON TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC. VIETNAM.

MAN 51 yo, ABDOMINAL PAIN AND BLOODY STOOL ONE WEEK AGO. ULTRASOUND DETECTED ONE MASS AT RIGHT SUBCOSTAL REGION WITH IMAGE LOOK LIKE OINION SIGN (IMAGE 1: CROSS-SECTIONAL VIEW, IMAGE 2: LONGITUDINAL VIEW) WITH THE REPORT BY SONOLOGIST ABOUT AN INTUSSUSCEPTION OF COLON.

MDCT SHOWED ONE SMALL TUMOR AND ITS CENTRAL PART REPRESENTED  A POLYP IN COMPARISON WITH MRI IMAGE.

The patient was admitted in emergency. Endoscopic colectomy showed the tumor making circular stenosis of ascending colon and inducing intussusception.

Macroscopic specimen is suspected a colon cancer, and microscopic report is  adenocarcinoma invasive of colon.

CASE 138: LIVER MASS of HCC, Dr PHAN THANH HẢI. MEDIC MEDICAL CENTER, HCMC VIETNAM

Man 55yo, epigastric pain, no fever. Abdominal ultrasound discloses a mass on left lobe of liver, size of 3 cm, hypoechoic, well-bordered, with the inhomogeneous central part. The mass represents avascular pattern on color Doppler.

Blood test : no raising of wbc counts, no infected  HBV or HCV virus, AFP in normal value.

On MRI with CE gado, this mass is enhanced and its central necrosis like CC (cholangiocarcinoma).

Laparotomy for exploration performs today. It is a left lobe of  liver tumor in invasion to left gastric curvature. Surgeon removes tumor and carries out a partial gastrectomy.

And now see the macro of specimen.

Microscopic report is HCC, undifferentiated cell.

 

 

DISCUSSION: Liver tumor is on left lobe of liver. Ultrasound findings are hypoechoic, hypovascular, invasion to gastric body, with blood tests of AFP, CEA, CA 19-9 are in normal values, and no infected HBV or HCV.
It is an atypical HCC.

CASE 137: APPENDIX TUMOR, Dr PHAN THANH HẢI , Dr LÝ VĂN PHÁI, Dr NGUYỄN THIỆN HÙNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Man 25 year-old was in pain at RLQ for 3 days. In abdominal ultrasound scans with curve probe 3.5 MHz (image 1), a cross-sectional view disclosed a big appendix in black border and its central part in white spot like bull-eye.

Image 2 in longitudinal section, the appendix was like a finger, noncompressible with white line in its center looks like an ascaris inside appendix.

Ultrasound with linear probe 12 MHz, (image 3: cross-sectional scanning) showed many rings in the center as intussusception.

Image 4, longitudinal section: the appendix with black content like mucocele.

But there was no raising of WBC in blood test. For verifying the appendiceal mucocele, a colonoscopy was done and detected this mass was like a finger covering by mucosa and protruding from appendiceal aperture (see photo).

It was hard, not content the mucus after many punctures, so it was thought to be a solid tumor according the report of endoscopist.

MDCT without CE also susgested a tumor of appendix (see CT image).

Via endoscopic laparoscopy, operation was done but surgeon could not detect any tumor of appendix. Open surgery detected the appendiceal tumor being an intracecal intussusception of appendix. And the surgeon removed the tumor after opening of cecum (see photo).

Microscopic histology and histoimmunostaining report is chronic inflammation and fibrosis of appendix.

 

Appendiceal intussusception into cecum is a rare condition so it could be detected in open surgery.

CASE 136: COLD ABSCESS, Dr PHAN THANH HẢI, Dr LÊ ĐÌNH VĨNH PHÚC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

WOMAN 31 YO COMPLAINED OF PAIN AT LEFT LOWER LUMBAR REGION, DIFFICULT WALKING, FOR ONE MONTH BUT NO  FEVER.

ULTRASOUND  EXAMINATION DETECTED A BIG MASS IN THE LOWER POLE OF LEFT KIDNEY, COVERED PSOAS MUSCLE AND  STORED AT LATERAL WALL OF ILIAC CREST. ITS CONTENT WAS VISCOUS FLUID WITH  DEBRIS. 

BLOOD TEST WITH RAISING OF WBC OF 11K WITH 65 % NEUTROPHIL.

MDCT  WAS  DONE IN DISCLOSING OF MANY LESIONS OF SPINAL BONES AND ILIAC  BONE.

We think it an abscess around the destruction bone (spinal and iliac ). Puncture for aspiration is done, the withdrawed pus was in brownish color, smelless.

During aspiration, the tip of needle is made doppler color due to the flow out of the pus (see video). At the iliac crest erosive the bone made doppler artefact like twinkling.
The pus is analysis: no bacteria, no BK present in direct microscope view. But ADA test is strong positive: 126 UI/L. It make a diagnosis of COLD ABSCESS due to BONE TUBERCULOSIS. (ADA: 100% sensitive, 98% specific).

Ref on ADA: ijcri-00203201122-dikensoy.pdf