Sri Ramakrishna Hospital’s Department of Gastroenterology recently performed breakthrough operations for 2 patients with very rare gastrointestinal disorders resulting in no postoperative complications. One such case was, a 68-year-old woman with a known HCV-related chronic liver disease with portal hypertension, complaining of abdominal pain for 15 days, who reached out to the hospital; she was treated with pegylated interferon alfa 12 years prior. A physical examination was recommended by the Gastroenterologists at Sri Ramakrishna Hospital, which revealed mild pedal oedema. A blood sample examination was conducted to analyze the levels of haemoglobin, total white blood cells, platelet count, blood urea and serum creatinine. Liver function tests showed normal bilirubin (TB), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels, but the doctors were determined to figure out the cause of the patient’s discomfort. The experts then proceeded with performing a CECT abdomen and it revealed a well-defined heterogeneously enhancing lesion (4.5 cm x 4 cm) with apical necrosis. The patient underwent positron emission tomography-computed tomography to confirm the same lesion. The patient also underwent EVS (Endoscopic ultrasound-guided biopsy, which showed features of HCC continued EHCC.
Understanding Ectopic Hepatocellular Carcinoma (EHCC):
EHCC is one of the uncommon carcinomas classified as an HCC originating from ectopic liver tissue, and it is typically detected inadvertently during autopsy or laparoscopy. The ectopic liver tissue can be noted in the gallbladder, spleen, pancreas, adrenal gland, diaphragm, thorax, retroperitoneum, and omentum. The most common place for an ectopic or auxiliary liver is the gallbladder, which accounts for around 0.56 per cent of reported cases. In this case, the patient was planned to undergo EUS-guided radiofrequency ablation as an alternative for the treatment of HCCs of small size. Some reports indicate that EHCC is present in approximately 7–30% of ectopic liver instances. The multistep process of carcinogenesis appears to be accelerated in these tissues. Due to the absence of a normal circulatory and ductal system, it is thought that the foci of ectopic liver tissue may be metabolically impaired, resulting in prolonged exposure to numerous carcinogenic agents. The underlying microenvironment could induce prolonged cellular stress, leading to cell death and compensatory cell growth.
EHCC can be distinguished from other tumours through the use of specific tumour markers and immunohistochemical analysis. Increased cell multiplication may result in genetic alterations and eventual carcinogenesis. The reason for this is that both morphological characteristics are similar. The diagnosis of EHCC is frequently challenging. It will be extremely difficult to identify morphologically between HCC and adenocarcinoma cells if the carcinoma cell is poorly differentiated or undifferentiated. The EUS-guided biopsy method is quite safer. The patient was successfully treated, and the lesion was removed without any postoperative complications.
With a similarly rare occurrence of another gastrointestinal disorder, a 17-year-old boy was brought to the hospital complaining about upper abdominal pain, back pain, and a fever of 1-week duration. A month ago, he was diagnosed with acute severe necrotizing pancreatitis (Idiopathic) and treated suggestive pancreatic pseudocyst. Physical examination indicated a soft, sensitive cystic lesion. After a routine checkup, he had an Endo-ultrasonography (EUS)-guided Cysto-Gastrostomy done while he was under general anaesthesia. Here’s how it worked: A linear echoendoscope was used to do the EUS (Olympus). Along the smaller curve of the stomach, a large, walled-off collection of 10 per cent solid and 90 per cent liquid was seen. About 500 ml of fluid was drained after a gush of necrotic fluid conservatively. After 2 days, the OGD was done again, and it showed that there was a solid piece of dead tissue inside the cavity. Intraoperatively, a diluted hydrogen peroxide solution was injected through a cannula, and the area was washed out. The patient was then sent home, and an endoscopy was done 8 weeks later which showed there was no dead tissue in the cavity. EUS Guided cysto-gastrostomy removed all of the dead tissue and kept the patient from needing major abdominal surgery.
Understanding Acute Pancreatitis:
Acute pancreatitis can be mild, moderate, or severe, depending on whether or not there is organ failure and whether or not there are local or systemic complications. Acute peripancreatic fluid collection (APFC), acute necrotic collection (ANC), pancreatic pseudocyst (PPC), and walled-off pancreatic necrosis (WOPN) are all local complications of acute pancreatitis. WOPN, whether it is sterile or infected, is marked by a clear capsule around dead pancreatic tissue. This usually happens 4 weeks after the first injury.
It has different amounts of solid trash in it. WOPN needs to be treated when it starts to cause symptoms, such as abdominal pain, infection, blockage of the gastric outlet, weight loss, or pressure on the biliary system. Drainage is the only way to treat WOPN. This can be done endoscopically, surgically, or percutaneously. But the best method is endoscopic drainage, especially with endoscopic ultrasound (EUS). The step-up approach started with percutaneous drainage, either endoscopic necrosectomy or minimally invasive retroperitoneal necrosectomy. Endoscopic necrosectomy is a less invasive and less risky way to treat infected WOPN and pseudocysts with solid debris than open surgical necrosectomy.
Here are a few signs that might indicate it is the time to visit a gastroenterologist:
- Facing difficulties while swallowing
- Acidity and indigestion
- Blood vomiting
- Chronic diarrhea
- Constant abdominal pain
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