Background: Gallbladder polyps are considered pre-malignant lesions of gallbladder carcinoma. This study aims to highlight the role of early cholecystectomy in the management of gallbladder polyps in an endemic population. Methods: A retrospective analysis of 2,076 lap cholecystectomy procedures performed at the Department of Surgical Gastroenterology at a tertiary referral centre in Northern India was conducted and incidental malignancy in gallbladder polyps analysed. The 8th edition of the American Joint Committee on Cancer for tumour-node-metastasis (TNM) staging of gallbladder carcinoma was used. Results: Of 54 patients with gallbladder polyps, 53 had benign histology and one had malignant cells in the lamina propria suggestive of T1a adenocarcinoma. The patient with the malignant polyp was older (57 years old) than the patients in the non-cancer group, which had a mean age of 45 (P = 0.039). The size of the malignant polyp was approximately 4 mm, significantly smaller than the average 7.9 mm size of the benign polys (P = 0.031). Conclusion: Cholecystectomy needs to be considered early in the management of small- sized gallbladder polyps, particularly in areas endemic for gallbladder carcinoma.
A 65-year-old post-menopausal female with no medical comorbidities (diabetes/hypertension), presented to the Emergency Department with complaints of altered sensorium, preceded by generalized malaise and sweating for 2 hours. There was no history of chest pain, headache, respiratory distress, prior fainting episodes and trauma. On examination, she was cold and clammy with pulse rate of 130 per minute, blood pressure of 90/60mm of mercury in supine position and respiratory rate of 22/minute. Her pupils were normally reacting to light. There was no pallor and cyanosis. On systemic examination, she had an irregular large lump about 15x18 cm in size located in the hypogastruim, firm in consistency, non-tender with restricted mobility. She had a GCS score of 10/15, cranial nerve examination were normal. Her reflexes were sluggish with a normal plantar reflex. Her haematological investigations and serum biochemistry including liver and renal function tests and electrocardiogram were normal except for the presence of blood glucose levels of 23mg /dl. She was given 200ml of 25% dextrose following which she regained consciousness and sugar levels returned to normal. Her hypoglycaemia was intractable and repeatedly 25% glucose had to be administered to maintain euglycaemia. Her troponin, thyroid profile, cortisol, prolactin levels were normal. Contrast Inhanced Computed Tomography (CECT) abdomen showed a multi-lobulated heterogeneous abdomino-pelvic mass with areas of necrosis and calcifications [Table/ Fig-1]. Right ureter was encased by the mass with evidence of mild hydronephrosis on the same side. The uterus was displaced superiorly by the mass and cervix was not visualized separately [Table/ Fig-2]. There was no metastasis or any other space occupying lesion in the abdomen. CECT Brain did not show any evidence of stroke or space occupying lesion. USG guided biopsy was done which was consistent with the diagnosis of GIST (CD 34 positive, CD117 negative) . To delineate the cause of intractable hypoglycaemia, serum insulin was done which was 4mU/L, (normal 6-25) and C-peptide was 0.3nmol/L (normal 0.33-1.0). Serum proinsulin levels were 56.4 (normal < 18.8pmol/l). IGF levels could not be done due to laboratory limitations. Due to suppressed insulin levels and raised proinsulin levels, the diagnosis of IGF-II dependent Non-islet Cell Tumour induced Hypoglycaemia (NICTH), was considered. Due to poor general condition and inoperability of the tumour, Methylprednisolone was started and she was gradually weaned off from Dextrose infusions. Right ureter was stented. When she became stable, she was started on Imatinib 400 mg/day to which her symptoms and hypoglycaemic episodes responded. The management requires prompt intravenous hydration and glucose infusions followed by surgical resection. We hereby, report a rare case of a 65-year-old female with intractable fasting hypoglycaemia due to overproduction of "big" insulin-like growth factor II diagnosed to have pelvic GIST and managed by Steroids and Imatinib.[ [
Cystic liver lesions in an adult may occur for a variety of reasons, most of which are benign in nature. Infiltrating benign lesions in the liver parenchyma may pose a clinical challenge in diagnosis and management. In the case presented herein, a cystic lesion adjacent to the gall bladder and involving the liver parenchyma had to be differentiated from gall bladder carcinoma, which is quite common in India. Parasitic infestation of the liver is an extremely rare presentation and may pose a significant challenge in its diagnosis and management. This case highlights an infrequent presentation and the challenges in the clinical approach and subsequent management.
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