A 49-year-old man presented with abdominal pain and rectal bleeding for two days associated with a 50-pound unintentional weight loss. History was notable for hypertension, chronic kidney disease, obesity, gout, and acute cholecystitis status post cholecystectomy. Computed tomography (CT) of the abdomen and pelvis showed rectal wall thickening. Colonoscopy showed proctitis with superficial ulcerations. In the setting of renal insufficiency, malabsorption, and low-voltage QRS complexes on electrocardiogram (ECG), amyloidosis was considered in the differential diagnosis. Rectal and renal biopsies with subsequent retrospective staining of gallbladder tissue confirmed amyloid deposition. Gastrointestinal involvement of amyloidosis is relatively uncommon. Particularly, amyloid deposition in the gallbladder and rectum is very rare. The development of AA amyloidosis in our patient may have been related to gout, obesity, and the presence of a heterozygous complex variant for the MEFV (familial Mediterranean fever) gene. Awareness of this atypical presentation of amyloidosis is important, as additional staining of biopsy samples is necessary, and diagnosis allows for directed treatment.
Pancreaticoduodenectomy, or Whipple procedure, is a high-risk surgical procedure commonly performed for tumors of the pancreatic head. The pancreatico-enteric anastomosis is an important component of this procedure. The maturation and adequate healing of this anastomotic site is critical to decrease the risk of postoperative pancreatic fistulas. The use of stents can help in the healing of this anastomotic site. We present a patient with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy, and presented with progressively worsening lumbar pain 7 years later. The patient was found to have osteomyelitis as a complication from an entero-spinal fistula secondary to a migrated pediatric feeding tube that was placed at the pancreaticojejunal anastomosis.
GOO is often the first sign of advanced upper gastrointestinal neoplasms. The most common neoplasms associated with GOO include gastric, pancreatic, and biliary tract cancers. Urinary tract urothelial carcinoma has been a rarely documented cause of GOO.
Gastrointestinal stromal tumors (GIST) are uncommon tumors accounting for 1% of gastrointestinal neoplasms. The most common location of GISTs is in the stomach. Commonly, these tumors present incidentally with an increased presence within older patients. Spontaneous rupture of a GIST is a rare presentation of this uncommon tumor. Our case highlights the diagnostic dilemma and imaging that helped diagnose an abnormal presentation of a ruptured GIST in a young patient.
Cholangiocarcinoma is a rare clinical entity representing approximately 2% of all cancers diagnosed. More than 65% of these tumors can present at the bifurcation of the hepatic duct and are known as Klatskin tumors. Pancreatic cancer is among the top 5 leading causes of cancer death, and it usually presents at an advanced stage with metastasis commonly seen in the liver. We report a patient with established pancreatic adenocarcinoma who presented with an obstructing mass at the hepatic duct bifurcation without any prior history of biliary tract disease. This represents a new diagnosis of either intracholedochal metastatic tumor or a new diagnosis of cholangiocarcinoma found at the hepatic duct bifurcation without liver involvement in the setting of pancreatic cancer, suggesting metachronous cholangiocarcinoma with pancreatic adenocarcinoma.
approach. An enlarged lymph node was identified in peripancreatic region measuring 24.2 mm by 10.9 mm, an additional fine needle biopsy was obtained. Pathology of pancreatic mass and lymph node later revealed fragments of lymphoid tissue consistent with reactive lymph node with single cluster of cytologically mildly atypical cells however no evidence of metastatic malignancy was appreciated. Immunohistochemical staining was positive for CD3 and CD20. CD56, chromogranin, synaptophysin, CD10, e-cadherin and AMACR stains were negative. Flow cytometry analysis was ordered. It demonstrated no evidence of a lymphoproliferative disorder. A three-month post procedure MRI was obtained which demonstrated a 1.6 cm nodule at neck of the pancreas increased in size when compared to prior image. (Figure ) Discussion: In immunology, TLS are a highly debated topic as to whether they serve as mediators of protective or pathologic immune responses in certain chronic inflammatory diseases and in the regulation of immune responses. When associated with both primary and or metastatic tumors they're known as tumor-associated TLS (TA-TLS). In cancer their presence is associated with prolonged increased rates of disease-free survival. When identified flow cytometry should always be ordered in order to rule out a lymphoproliferative disorder. TLS and its implications are still an area of active study, clear guidelines in terms of management are still being developed. Furthermore as to whether they represent premalignant lesion is still unknown. Our patient remains asymptomatic and continues to be monitored with serial imaging.[1842] Figure 1. A. Magnification 200x. Small fragment of benign pancreatic acinar cells near lymphoid cluster. B. Magnification 100x. Aggregates of lymphoid tissue with intervening capillaries representing lymph node like structure within pancreas. C. MRI Abdomen with contrast showing 1.3 cm enhancing nodule at neck of pancreas. D. EUS. Fine needle aspiration of 11.4 mm by 8.5 mm intrapancreatic mass.
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