Pulmonary hypertension and cor pulmonale due to tumor emboli causing pulmonary tumor thrombotic microangiopathy (PTTM) is rare and extremely difficult diagnosis to make prior to death. Pulmonary hypertension due to metastatic tumor emboli should be included in the differential diagnosis of various causes of dyspnea in patients with a history of cancer or more common causes, including infection, thromboembolism, metastasis, adverse effects of drugs, and recurrent effusions. We describe a patient with gallbladder carcinoma who presented with progressive dyspnea and severe pulmonary hypertension. The etiology was tumor emboli and PTTM from gallbladder carcinoma, which remained elusive prior to her death despite appropriate clinical investigations and was established on autopsy. To the best of our knowledge, this is likely the second reported case of PTTM from metastatic gallbladder carcinoma.
Background and study aims
Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive diagnostic and interventional procedure used in conditions related to the pancreas and biliary tract. It has a complication rate ranging from 4 % to 10 %. Severe complications are few with the most common of them being post-ERCP pancreatitis, post-sphincterotomy bleeding, and perforation. A rare, but potentially life-threatening complication of ERCP is splenic injury. We report the case of a 60-year-old female with choledocholithiasis who sustained splenic decapsulation following ERCP. The exact causes of splenic injury are unknown, although several mechanisms are postulated. A literature review of splenic injuries post-ERCP shows that there are only 3 cases with post-ERCP splenic decapsulation. Our patient is the first one in whom splenic decapsulation occurred without any risk factors or technical difficulties during the procedure. A high index of suspicion for splenic injury is required in any patient who has severe pain, anemia, or hemorrhagic shock after ERCP.
A 47-year-old woman underwent elective right upper lobectomy with pneumopexy for adenocarcinoma. On postoperative day 2, she had tachycardia, and her chest radiograph, bronchoscopy, and computed tomography chest scan were suspicious for pulmonary torsion. She underwent emergent thoracotomy, and the right middle lobe was not torsed; it was purple, engorged, and not ventilated. The patient did well after right middle lobectomy. We suspect compromised middle lobe pulmonary venous drainage due to angulation after compensatory expansion. This uncommon phenomenon has not been described previously. High suspicion for pulmonary torsion and treatment led to avoidance of complications such as infection, gangrene, infarction, thromboembolism, and death.
Background
Intraoperative measurement of intact parathyroid hormone (iPTH) has been used increasingly as a means of confirming complete removal of hyperfunctioning parathyroid tissue. It remains uncertain, however, whether normalization of iPTH levels at operation accurately predicts postoperative values of iPTH.
Methods
Forty-five consecutive patients with primary hyperparathyroidism underwent parathyroidectomy between March and November 1999. Baseline intraoperative iPTH levels were measured before and at manipulation, then subsequently at 5 and 10 min after tissue was removed. Follow-up values were measured at 1- and 3-month intervals.
Results
Before operation the mean(s.d.) iPTH concentration was 211(182) pg ml−1 with a mean serum calcium level of 11·4(1·0) mg dl−1. In all but four patients, the final intraoperative iPTH normalized to absolute values below 60 pg ml−1 (mean 38(36) pg ml−1). One week after operation, serum calcium levels had returned to normal (mean 9·2(0·9) mg dl−1) and this correlated directly with final intraoperative iPTH values when assessed by linear regression analysis (r = 0·373, P < 0·03). By 1 month, all but two patients were normocalcaemic (mean 9·6(0·6) mg dl−1) with a mean iPTH of 81(99) pg ml−1. There was no correlation between the final intraoperative iPTH and postoperative iPTH values as determined by linear regression analysis (r = 0·035, P < 0·881). Both patients with persistent hypercalcaemia at 1 month had appropriate intraoperative decreases in iPTH level.
Conclusion
Although there is significant correlation between intraoperative iPTH levels and postoperative serum calcium levels, this does not hold true for postoperative iPTH levels. There was a 4 per cent failure rate in correcting postoperative calcium levels and a 20 per cent failure rate in normalizing postoperative iPTH levels despite appropriate intraoperative decreases in iPTH.
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