Perplexing Severe Cholestasis in the Postpartum Period.

The presentation of right upper quadrant abdominal pain is common, non—specific and challenging to diagnose. Right upper quadrant (RUQ) pain can be benign but may also signal serious pathology. Early diagnosis is key to preventing possible complications. This case aims to highlight a presentation of RUQ pain in a young male which heralded a more sinister pathology. A previously healthy 36year—old male presented with one—week of intermittent fevers and progressive sharp RUQ pain with chills, night sweats, early satiety and fatigue. Initial assessment was significant for HR 116, RUQ tenderness with guarding, no rebound or organomegaly. Laboratory findings were only significant for lactate 11.08mg/dL. Cultures were negative, AFP was normal. HIV, HBV and HCV were negative.Abdominal ultrasound revealed heterogeneous large right hepatic lobe mass suggestive of hemorrhage, hepatic adenoma, metastasis, fibrolamellar hepatocellular carcinoma (HCC) or hepatic abscess. MRI with contrast had similar findings with large non—enhancing geographic regions, T2—hyperintense and T1—hypointense, consistent with necrosis or blood products. MRI was suggestive of atypical HCC, fibrolamellar HCC, angiosarcoma or metastases; hepatic adenoma unlikely in the absence of risk factors. CT—guided biopsy revealed hepatic neoplasm favoring adenoma with atypical findings evidenced by immunostaining, diffuse strong glutamine synthetase staining and no nuclear beta—catenin staining, positive serum amyloid A, and retained LFABP. Glutamine synthetase staining was concerning for beta—catenin invasion. He underwent a right hepatic lobectomy, with pathology finding of hepatic adenoma, and no recurrence at 1—year follow—up. Hepatocellular adenomas (HCA) are rare, benign tumors which occur mostly in women and are strongly associated with the use of estrogens, anabolic and androgenic steroids. There are no specific diagnostic serologic or imaging studies. The new Bordeaux HCA subtype classification is based on genetic and phenotypic characteristics and provides insight into the pathological and radiological diagnosis and clinical management. Complications such as rupture, hemorrhage and malignant transformation to HCC increase mortality markedly. Mortality is low when recognized and treated early. It is, therefore, an important differential to consider in a patient with RUQ pain in the presence of a liver mass with no underlying cirrhosis. The absence of risk factors does not exclude the diagnosis.3020_A.tif Figure 1: Abdominal ultrasound: Large heterogeneous right hepatic lobe mass with suggestion of internal hemorrhage.3020_B.tif Figure 2: Contrast—MRI, coronal and axial views: marked enlargement of the right hepatic lobe secondary to a large mass with intrahepatic blood products suggesting rupture/hemorrhage3020_C.tif Figure 3: Liver biopsy histology: Hepatocellular neoplasm, favor adenoma with atypical findings. Diffuse strong glutamine synthetase staining, serum amyloid A positive, retained LFABP, no nuclear beta—catenin staining and noncontributory reticulin special stain

Su1337 Sphincter of Oddi Manometry in Patients With Chronic Right Upper Quadrant Pain and Idiopathic Acute Pancreatitis: Role of Repeat Manometry in Patients With Recurrent or Persistent Symptoms

Adrenal infarction is an infrequent cause of severe abdominal pain during pregnancy. The magnetic resonance imaging (MRI) features of adrenal infarction have not previously been thoroughly described. A 20-year-old woman, gravida 1 para 0, presented at 27 4/7 weeks of gestation with sudden-onset right upper quadrant and flank pain. A 29-year-old woman, gravida 2 para 1, presented at 17 5/7 weeks of gestation with sudden-onset right abdominal and flank pain and again at 35 5/7 weeks of gestation with sudden-onset severe left flank and upper quadrant pain. In both patients, unilateral adrenal infarction was diagnosed on contrast-enhanced computed tomography after initial nondiagnostic ultrasonography and MRI. Clinical presentation and MRI features of nonhemorrhagic adrenal infarction are described. Nonhemorrhagic adrenal infarction may be an underdiagnosed cause of acute abdominal pain during pregnancy and can be diagnosed with MRI.

Background & Objective: Plastic anemia, a rare hematological disorder resulting inpancytopenia, is primarily managed through immunosuppression. Anti-thymocyteglobulin (ATG), a polyclonal antibody derived from equine or lapine sources, is onesuch immunosuppressive treatment. While common side effects of ATG include allergicreactions, thrombocytopenia, headache, and myalgia, more severe but less frequentadverse effects encompass dyspnea and chest pain. The incidence and severity of liverfunction test abnormalities associated with ATG administration remain subjects ofongoing debate; however, most cases present with mild and transient enzyme elevations. Case: We present the case of a 13-year-old male child diagnosed with aplastic anemia (AA) who was admitted to the hematology clinic for ATG treatment. Three days after the initiation of ATG therapy, following the third dose, the patient developed severe hepatotoxicity. The patient experienced symptoms including chest pain, icterus, myalgia, and abdominal tenderness. Laboratory investigations revealed a significant elevation in liver enzymes and serum bilirubin levels. Upon discontinuation of ATG, the symptoms resolved within six days, accompanied by a marked reduction in liver enzymes and bilirubin levels. Subsequently, the patient received the fourth dose of ATG without adverse reactions Conclusion: Our patient developed frank symptomatic hepatitis, manifesting as icterus and right upper quadrant pain. Given the existing literature, this presentation does not appear to be common and warrants increased vigilance

Obstructive jaundice occurs when an obstruction in the bile duct system prevents bile from flowing from the liver into the intestine, accumulating bilirubin in the blood. This condition can result from various causes, including gallstones, tumors, or inflammation of the bile ducts. The management of obstructive jaundice depends on the underlying cause (malignant obstructions such as cholangiocarcinoma or pancreatic cancer), indicating the need for surgical intervention. The Whipple procedure (pancreaticoduodenectomy) is the standard curative approach for resectable distal common bile duct (CBD) adenocarcinoma. Doctors usually recommend adjuvant chemotherapy to reduce the risk of recurrence. We report the case of a 70-year-old male with a history of untreated hypertension, type 2 diabetes, and long-term smoking, who presented with classic signs of obstructive jaundice, including yellowing of the eyes, itching, right upper quadrant pain, and intermittent fevers. Laboratory findings revealed elevated inflammatory markers, bilirubin, liver enzymes, and leukocyte count, indicative of an inflammatory and obstructive biliary condition. Imaging studies confirmed a distal CBD stricture, including abdominal ultrasound, computed tomography scans, and endoscopic retrograde cholangiopancreatography (ERCP). Brush cytology obtained during ERCP revealed a well-differentiated adenocarcinoma of the distal CBD. The patient's treatment plan included preoperative optimization, surgical resection via the Whipple procedure, and postoperative adjuvant therapy. This case emphasizes the importance of a thorough diagnostic workup and a multidisciplinary treatment strategy in managing complex cases of obstructive jaundice in the elderly, highlighting the need for personalized care to achieve optimal outcomes.

A 33-year-old primigravida at 32-week gestation was admitted to labor and delivery complaining of severe right upper quadrant pain and worsening coagulopathy. We report the anesthetic and obstetrical management of a complex case of a parturient with a mixed picture of hemolysis, elevated liver enzymes and low platelets who was delivered under general anesthesia further complicated by Disseminated Intravascular Coagulopathy (DIC) and placental abruption.

Over the past several years, clinicians have become aware of the importance of maintaining a positive nitrogen balance in hospitalized patients. This has led to the widespread use of total parenteral nutrition (TPN). However, with increased experience with this form of nutrition, numerous potential complications have been uncovered. One of the complications demonstrated with increased frequency is that of abnormal liver function, manifested by elevated serum liver enzymes. This report describes a 44-year-old woman with rectal abscesses and possible inflammatory bowel disease who developed severe right upper quadrant pain, abnormally elevated liver enzymes, and elevated body temperature during her course of TPN therapy. These problems possibly were related to the TPN regimen. Once TPN therapy was discontinued, the patient's liver enzyme values and elevated body temperature began to return to baseline. She subsequently was discharged from the hospital. A follow-up visit to the physician's office revealed that all liver enzyme values had returned to normal, the pain had resolved, and she was recovering well.

Abdominal pain is a common presentation in the outpatient setting. Patients presenting to the emergency department with RUQ pain are often diagnosed with acute cholecystitis. The spectrum of diseases is also associated with RUQ pain including choledocholithiasis, biliary colic and liver pathologies. Ultrasoundis the first-line imaging modality opted to diagnose the cause of RUQ pain. More than one-third of patients suspected of having acute cholecystitis and right upper quadrant pain after the initial clinical evaluation are ultimately proved to have a different diagnosis.The objective of this study is to find sonographic findings in patients with acute RUQ pain and establish reasons of using Ultrasound in these circumstances. Material and Method: A total of 385 cases who were presented with RUQ pain in Sanabil Health Services Hospital were included in this descriptive observational study. 190 were female and 195 were male with a mean age of 44.7±13.4 years. A thorough scan of complete abdomen was done and results were analyzed through IBM SPSS statistics 28.0 version 2021. Results:Out of total 385 patients, 91 patients (23.6%) were suffering from cholelithiasis and only 19 (5.0%) of them had cholecystitis which are major causes of right upper quadrant pain. Majority of patients (26.8%) were diagnosed with Fatty liver disease, Obstructive kidney disease (17.4%) and a significant number of patients (14.5%) were also normal on Ultrasound scan. Conclusion:The Ultrasonographic diagnosis of majority of patients who are presented with right upper quadrant pain is fatty liver disease and other pathologies which are known to not cause any pain in right upper quadrant

IntroductionRight upper quadrant pain is a very common symptom of cholecystitis. Right upper quadrant pain caused by fish bone perforation of the stomach wall is rare.Case PresentationWe report a 42-year-old woman who was admitted to our hospital with “1-month history of dull progressive right upper quadrant pain radiating to the back.” Computed tomography of the abdomen revealed a linear, high-density body between the stomach wall and the liver. On history, the patient stated she had eaten a bony fish a month prior but did not note any significant pain at the time. Laparoscopy revealed a fish bone 2 cm in length half on the surface of the caudate lobe of the liver, and no perforation of the gastrointestinal tract was found. The postoperative course was uncomplicated, and the patient was discharged home on day 3 after surgery.ConclusionThe case of right upper quadrant pain caused by the fish bone is very rare. Radiological examinations play a significant role in the diagnosis of fish bone ingestion. Laparoscopic surgery is technically feasible and safe for the treatment of patients with fish bone ingestion.

Twenty human immunodeficiency virus (HIV)-positive patients were studied who presented with right upper quadrant abdominal pain, with or without abnormal biochemical liver function tests, in whom AIDS-related sclerosing cholangitis (ASC) was suspected. The results obtained from hepatobiliary scintigraphy using 99Tcm-IODIDA were compared with data from endoscopic retrograde cholangiopancreatography (ERCP), ultrasound and histological data from liver biopsy or post mortem. 99Tcm-IODIDA was abnormal in 14 patients. Liver biopsy, ERCP or post mortem confirmed ASC in 11 patients of whom 10 had an abnormal 99Tcm-IODIDA study. Ultrasound was performed in eight of the patients with confirmed ASC but was abnormal in only five of these. One patient with mild ASC on ERCP and Kaposi's sarcoma had a normal 99Tcm-IODIDA. In HIV-positive patients with right upper quadrant pain, imaging with 99Tcm-IODIDA provides a non-invasive screening test which may help to determine those patients who should be referred for ERCP.

Background: Antiviral therapy is not routinely recommended for chronic hepatitis B virus (HBV) infection in patients with elevated serum HBV DNA levels (>2000 IU/mL), normal alanine aminotransferase (ALT) levels, and no significant liver fibrosis, referred to as the “indeterminate phase.” This study aimed to identify factors associated with liver fibrosis progression in chronic HBV patients within this phase. Since the study’s design, hepatitis B treatment guidelines have undergone significant evolution. New WHO recommendations published in 2024 advocate for expanded treatment criteria, making terms like “Indeterminate phase” obsolete. Methods This retrospective longitudinal cohort study was conducted at Farhat Hached University Hospital in Sousse, Tunisia, from January 2008 to January 2022. We included HBsAg-positive patients who were untreated, had a viral load >2,000 IU/mL for at least six months, normal ALT (<40 IU/L), and a fibrosis score of F0 and/or F1 (determined by liver biopsy or FibroScan). Univariate and logistic regression analyses were performed to identify factors associated with liver fibrosis progression. Results A total of 97 patients were included, with a median age of 32.9 ± 9.1 years and a female predominance (M/F ratio = 0.64). Fibrosis progression occurred in 16 patients (16.5%), with a mean delay of 70.9 ± 41.1 months. Univariate analysis showed significant associations between fibrosis progression and comorbidities (p = 0.001), high initial viral load (p = 0.004), elevated liver enzymes (p = 0.001), and increased viral load during follow-up (p = 0.002). Multivariate analysis identified comorbidities (p<0.001) and changes in ALT levels (p<0.001) as independent predictors of fibrosis progression. Conclusion Comorbidities and changes in ALT levels during follow-up were associated with fibrosis progression in the indeterminate phase of chronic HBV infection. Our findings support recent changes in international guidelines, including those from the WHO in 2024, which expand therapeutic indications for individuals living with hepatitis B.

Introduction. Cystic duct anatomical variations are encountered frequently during surgical procedures. In this report, a female patient underwent laparoscopic cholecystectomy for acute cholecystitis and developed symptoms of obstructive jaundice subsequently, which was diagnosed as low insertion of the cystic duct and an impacted stone that was causing common hepatic duct obstruction. Case report. A 42-year-old female presented to the emergency room complaining of persistent right upper quadrant pain that was radiating to the back. White blood count (WBC) was slightly elevated with normal liver function tests (LFTs). An abdominal ultrasound was performed and confirmed cholelithiasis with no signs of acute cholecystitis or biliary dilatation. The patient underwent laparoscopic cholecystectomy as an emergency procedure for persistent biliary colic. Eight days later, the patient returned to the emergency room with obstructive jaundice and continued right upper quadrant pain with elevated WBC and LFTs. Further tests were conducted, and the patient was found to have a long cystic duct with a low insertion variant to the common hepatic duct. An impacted stone was identified in the cystic duct, referred to as Mirizzi syndrome Type I. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) several times, but the common bile duct could not be cannulated. In the last ERCP session, SpyGlass and electrohydraulic lithotripsy were performed with a balloon sweep. Conclusion. This case demonstrates the importance of understanding Mirizzi syndrome and cystic duct variation to achieve optimal treatment, and careful assessment and investigation are essential for proper diagnosis. In experienced hands, Mirizzi syndrome secondary to an impacted cystic duct stone can be managed successfully with ERCP, electrohydraulic lithotripsy, and SpyGlass.

This instance of gaseous cholecystitis is reported to illustrate the value of roentgenography in what appeared at first to be an uncomplicated choledocholithiasis. The patient, a 50-year-old white butcher, entered the hospital in January 1947. He had been in excellent health until the age of 52, when a mild diabetes mellitus developed, which was controlled by diet. In mid 1945, an attack of mild aching in the right upper quadrant of the abdomen occurred , without nausea or jaundice. The attack lasted for one day. There was no history of an idiosyncrasy to fried or fatty foods. On Jan. 18, 1947, about four hours after a roast pork dinner, the patient experienced a severe, steady, non-radiating pain in the right upper quadrant of the abdomen, with no nausea, vomiting, or chills. The pain subsided during the night, but a dull ache persisted. Two days later (Jan. 20), the patient was awakened at five o'clock in the morning by a recurrenee of severe right upper quadrant pain, which continued with diminishing intensity throughout the day. He ate alight lunch and supper and that night vomited bile. He also noticed that his urine was dark and foul and that his stool was black. He was seen by a physician and given morphine for relief of pain. A dull ache continued, however, and on Jan. 22, four days after the initial attack, he was again awakened early in the morning by severe right upper quadrant pain. He was seen that morning by his physician, who noted the presence of jaundice. The patient felt somewhat better during the next three days but the jaundice and right upper quadrant ache persisted. He entered the hospital for study on Jan. 26, 1947. The physical examination on admission revealed a moderate icterus. The liver was barely palpable and slightly tender to percussion. There was a sense of resistance in the right upper quadrant of the abdomen with slight tenderness in that area. No other abnormalities were noted. The temperature ranged between 100 and 102° F. Laboratory examinations revealed a slight elevation of globulin (3.9 gm. per cent) with normal albumin. The cephalin flocculation test was four plus. The thymol turbidity was within normal limits. The alkaline phosphatase was elevated, its highest level being W.O Bodansky units. The prothrombin time was slightly elevated. The van den Bergh reaction was prompt, with a reading of 14.8 mg. percent. The white blood count and differential count were normal. The red blood count was 4,800,000 on admission but this figure subsequently dropped to 3,800,000. Roentgen examination of the upper gastro-intestinal tract on Jan. 28, with contrast material, showed rather marked spasm of the prepyloric portion of the stomach, but no intrinsic lesion was demonstrated. During a review of the films on the following day, a persistent, rounded gas shadow was observed in the gallbladder area.

A 64-year-old man presented with sharp, constant right upper quadrant pain, nausea, and constipation for 2 days. The patient reported intermittent right upper quadrant pain for the prior 6 years, which was exacerbated by eating, but noted that over the past 2 days the pain had become more severe. The patient had previously undergone three right upper quadrant ultrasound studies that were all negative for acute cholecystitis. On presentation, examination was notable for focal tenderness to palpation over the xiphoid process. A right upper quadrant ultrasound study was completed, and demonstrated a single hepatic cyst and gallbladder sludge without evidence of gallstones, gallbladder wall thickening, pericholecystic fluid, or a sonographic Murphy’s sign (Fig. 1). A chest radiograph was obtained, and demonstrated elevation of the right hemidiaphragm with colonic interposition in the right upper quadrant (Fig. 2). Computed tomography of the abdomen and pelvis with intravenous and oral contrast was performed, and demonstrated a large right-sided anterior diaphragmatic hernia containing distended loops of colon with short segment narrowing at the entrance as well as soft tissue stranding and simple fluid within the herniation sac, consistent with an incarcerated Morgagni hernia (Fig. 3). The patient underwent laparoscopic diaphragmatic hernia repair with mesh, which was complicated by postoperative development of a right pneumothorax, but with eventual normalization of the chest radiograph (Fig. 4) and resolution of the right upper quadrant pain.

IntroductionMirizzi syndrome is a rare complication of gallstone disease. The purpose of this report is to describe the utility of laparoscopic subtotal cholecystectomy for Mirizzi syndrome. Presentation of caseA 53-year-old female presented with dark urine and right upper quadrant pain. Blood tests revealed elevated liver and biliary enzyme levels. Magnetic resonance cholangiopancreatography showed a narrowed common hepatic duct compressed by a large gallstone, consistent with Mirizzi syndrome. Semi-urgent laparoscopic cholecystectomy was planned. At operation, circumferential dissection of the gallbladder neck was difficult. The fundus of the gallbladder was opened and a 2 cm stone extracted. The gallbladder neck was sutured and a drain placed. The postoperative clinical course was uneventful. DiscussionAfter laparoscopic cholecystectomy in patients with Mirizzi syndrome, complication rates, including bile duct injuries, is high. In patients with Mirizzi syndrome, removal of the responsible stone is the main purpose of treatment. ConclusionLaparoscopic subtotal cholecystectomy is a useful technique for patients with Mirizzi syndrome to avoid bile duct injury.