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Two cases of catheter embolization from implanted venous access devices are reported and the available literature is reviewed. The catheter from an implanted venous access device migrated into the right heart after slippage of the O-ring, which attaches the catheter to the infusion port. The distal 6 cm of an infusion port catheter embolized to the right heart after spontaneous fracture of the catheter at the point where it passed between the clavicle and first rib. Both catheters were removed percutaneously without complication. Risk factors for embolization were apparent on x-ray films with evidence of O-ring slippage in 1 case an obvious kinking of the catheter in the other. Symptoms of embolization included chest discomfort, right upper quadrant pain, and nausea. In 1 case, an extra heart sound, initially thought to be an S3, disappeared when the catheter was removed.
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PMID:Catheter embolization from implanted venous access devices: case reports. 270 40

Differential diagnosis of viral hepatitis begins with a check for darkened urine and bile in the urine. These hallmarks of conjugated hyperbilirubinemia immediately rule out prehepatic liver disease. Next, studies are done for the elevated transaminase levels that are characteristic of hepatitis infection, and a thorough history is taken to rule out drug- and toxin-induced hepatitis that may mimic acute viral hepatitis. Elevated alkaline phosphatase is a good marker of cholestasis. Ultrasonography can clarify this diagnosis. The classic presenting symptoms of viral hepatitis are jaundice, nausea, vomiting, malaise, anorexia, and dull right upper quadrant pain. However, serologic studies are needed to detect the presence of specific viral agents.
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PMID:Viral hepatitis. The alphabet game. 305 Sep 28

Intraarterial administration of 40-microns degradable starch microspheres (DSM) in a drug solution can temporarily retard flow of the drug-blood column through the arteriolar-capillary bed and lead to increased local drug deposition. Premonitory to Phase II-III efficacy studies applying this concept to regional therapy, it was necessary to determine the DSM dose to use. Patients with hepatic cancers were treated with varying doses of DSM with mitomycin C coadministered into the hepatic artery to define a dose of DSM which produces acceptable toxicity with maximal hepatic drug deposition as determined by a reduction in systemic mitomycin C exposure. Comparison of six patients receiving 6 ml of DSM (6 X 10(6) particles/ml) with ten patients receiving 15 ml showed a lower incidence and decreased severity of acute toxicity in terms of nausea/vomiting (16% versus 50%) and right upper quadrant hepatic pain (none versus 40%) with 6 ml of DSM. Reduction in systemic mitomycin C exposure evaluated by decrements in the area under the concentration curve in peripheral blood with time due to DSM was similar in both groups. Another seven patients were treated with escalating doses of DSM concurrently with 5 mg of mitomycin C. Although all seven patients tolerated 6 ml of DSM, higher doses (9 ml, 12 ml, 15 ml) led to incremental patient drop-out due to severe, acute right upper quadrant pain with only two patients able to receive 15 ml of DSM. In these patients, 6 ml of DSM appeared nearly equivalent to higher doses in terms of systemic exposure to mitomycin C. Eleven additional patients were evaluated for tolerance to repeated 6-ml dosing of DSM. Four patients had epigastric pain correlating with flow to the stomach demonstrated by nuclide angiography. The seven patients with no pain and no flow to stomach were treated with good tolerance for three-plus courses. Thus, 6 ml of DSM appear to be appropriate for Phase II-III studies.
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PMID:Phase I study of hepatic arterial degradable starch microspheres and mitomycin. 392 57

The possible association of hepatocellular carcinoma with oral contraceptive (OC) use is supported by the case of a 33-year old black female, gravida 5, para 4. She presented in April 1978 with right upper quadrant pain, nausea, vomiting, and fatty food intolerance. The case had been taking norethindrone, 1 mg with mestranol 0.05, for 2 years. There was no history of liver disease, alcohol abuse, or exposure to chemical toxins. The preoperative diagnosis was subacute cholecystitis; however, an unresectable primary liver tumor of both lobes was detected on surgery. OC use was discontinued, and the case refused chemotherapy. On December 1, 1978, she presented with a 9-week pregnancy which was aborted. Physical examination revealed an enlarged liver and mass in the upper right quadrant. The patient was readmitted December 11 with intractable pain and discharged. She died December 28, 1978. At autopsy the liver tumor appeared as a moderate to poorly differentiated hepatoma with irregular hyperchromatic nuclei. There was no evidence of coexistent benign lesions. The rapid progression of the disease following pregnancy suggests that hepatic growth was stimulated by the high estrogen levels of pregnancy. Earlier diagnosis and improved management are required in such cases. Ultrasonography can be used to confirm the presence of a mass, and liver scan or hepatic angiogram may be useful. Liver biopsy is required for definitive diagnosis. Treatment involves discontinuation of OC use and complete excision of the tumor where possible. If tumors have progressed beyond the stage of resectability, as in this case, the prognosis is poor.
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PMID:Hepatocellular carcinoma associated with oral contraceptive use and pregnancy. 629 72

A 32-year-old woman with a contraceptive history of use of combination contraceptives (Oviston, Non-Ovlon) between 1966 and 1979 (with a 1-year interruption), followed by radical hysterectomy in 1979, complained of dull right upper quadrant pain, nausea, vomiting, and fatigue in 1980. Among various diagnostic studies performed only cholecystography and cholangiography demonstrated clear areas in the gallbladder assumed to be stones. Cholecystectomy performed in 1981 showed chronic inflammation of the gallbladder without stones. The undersurface of the liver revealed a greyish tumor (3 cm in diameter). Frozen section demonstrated mature hepatocellular adenoma. Wedge excision of the tumor and cholecystectomy were performed without complications. CAT-scan follow-up showed no residual pathology. Additional literature search reports 58 cases in western European and American journals. Diagnosis of these benign tumors is difficult because the symptoms are vague. The main complication is intraabdominal hemorrhage necessitating emergency lobectomy. Ligation of a branch of the hepatic artery is done in case of inoperability. CAT-scan and ultrasonography with selective angiography are the best procedures to ascertain the diagnosis. Needle biopsy is contraindicated because of the risk of hemorrhage.
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PMID:[Hepatocellular adenoma following long-term intake of ovulation inhibitors]. 630 51

Laparoscopic cholecystectomy in a freestanding outpatient surgery center was evaluated. Fifty-five patients undergoing laparoscopic cholecystectomy during a 10-month period from December 1992 to October 1993 were included in this study. There were 10 males and 45 females, with a mean age of 42 years. All patients had a history consistent with biliary colic. Forty-nine patients had documentation of cholelithiasis by ultrasonography, 3 had documentation of cholelithiasis by other diagnostic procedures, and 3 had a diagnosis of biliary dyskinesia. The mean surgery time was 75 min, with a range of 43-145 min. Fifty-four intraoperative cholangiography attempts were made, and 81% were successful. In 19%, intraoperative cholangiography was unsuccessful secondary to a small cystic duct. Fifty of the patients (90%) in this study were discharged from the surgery center without significant sequelae. Four patients were admitted to the hospital postoperatively, 1 for bradycardia, 1 for nausea, 1 for i.v. antibiotics secondary to purulent cholecystitis, and 1 for inability to maintain an adequate oxygen saturation. Another patient was admitted 1 week postoperatively for right upper quadrant pain. After a negative hepatobiliary scan, this patient was discharged without sequelae. The average facility charge of laparoscopic cholecystectomy in this series was $2300, compared with the average charge of $6500 in our community hospital. We conclude that laparoscopic cholecystectomy can be performed safely and cost effectively in a freestanding outpatient surgery center with proper patient selection.
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PMID:Laparoscopic cholecystectomy in a freestanding outpatient surgery center. 783 11

Spontaneous rupture of the liver associated with pregnancy is a rare and grave complication, usually occurring in preeclampsia or eclampsia. Two cases of ruptured subcapsular hematoma of the right liver during pregnancy are reported. The first case was a 19-year-old woman who had suffered from epigastralgia and absent fetal heart beat in the 32nd week of gestation. The second case was a 31-year-old female who complained of nausea and right upper quadrant pain in the 35th week of pregnancy. Both had preeclampsia, and developed shock with disseminated intravascular coagulation soon after admission. Both received surgery and were found to have ruptured hematoma over the right liver. Finally, the first patient died of renal failure, but the second survived because preoperative diagnosis had been exact. Greater suspicion, then awareness of diagnosis can lead to better timing of surgery and an improved prognosis for mother and child.
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PMID:Spontaneous rupture of the liver associated with pregnancy: a report of two cases. 798 38

The term biliary pseudolithiasis was coined by Schaad (1988) to describe the appearance of gallbladder sludge following treatment with ceftriaxone. After cessation of the drug the condition resolves, hence the term "pseudolithiasis." The third generation cephalosporin, cefatriaxone, is a very potent, broad spectrum antibiotic indicated in meningitis, osteomyelitis, pyelonephritis, Lyme disease and many other severe infectious diseases. Up to 46% of those receiving this antibiotic develop gallbladder sludge. Most are asymptomatic, but a small proportion may develop right upper quadrant pain, nausea, vomiting and even cholecystitis. Ultrasonography may demonstrate many, small, echogenic particles within the gallbladder, as well as larger echogenic foci casting acoustic shadows. However, it can not differentiate these pseudostones from real stones. There are reports of surgical intervention in such cases. 2 boys, aged 5 and 10 years, respectively, treated with ceftriaxone for meningitis are presented. Both developed symptoms during treatment and in both gallbladder sludge was identified by ultrasonography. In 1 intraluminal gallbladder findings were identical with the appearance of surgical stones. Follow-up ultrasonography after the drug was stopped showed no evidence of pseudostones in either case. Awareness of this phenomena might save many unnecessary operations.
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PMID:[Sonographic demonstration of pseudo-cholelithiasis after ceftriaxone]. 799 84

There are increasing challenges for the practising gastroenterologist in treating AIDS-related gastrointestinal diseases. The differential diagnoses of dysphagia and odynophagia include cytomegalovirus (CMV) and herpes simplex virus (HSV) infection, non-specific aphthous ulceration and non-AIDS oesophageal diseases, especially reflux oesophagitis. Chronic subacute abdominal pain with nausea, vomiting, early satiety and weight loss is suggestive of an obstructive lesion caused by lymphoma or Kaposi's sarcoma. Severe acute abdominal pain can indicate pancreatitis or intestinal perforation due to cytomegalovirus. Right upper quadrant pain (with or without fever, vomiting or abnormal liver function tests with a cholestatic profile) is suggestive of hepatobiliary pathology including cholecystitis, cholangitis, acalculous cholecystitis and AIDS cholangiopathy. Diarrhoea is the most common gastrointestinal symptom of AIDS, affecting 50-90% of patients. Causes of AIDS diarrhoea include protozoa (Cryptosporidium parvum, Isospora belli, Enterocytozoon bieneusi, Septata intestinalis, Cyclospora spp, Entamoeba histolytica and Giardia lamblia), bacteria (Mycobacterium avium-intracellulare, Clostridium difficile, Salmonella, Shigella and Campylobacter jejuni), and viruses (CMV, HSV and possibly HIV). Chronic diarrhoea, malnutrition and weight loss can shorten the life-span of patients with AIDS. Elemental diets, isotonic formulas, medium chain triglycerides and total parenteral nutrition have been tried with little success in AIDS patients with severe diarrhoea and wasting.
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PMID:AIDS and the gut. 805 32

We describe a 54-year-old woman who had severe anemia as the initial presentation of a pyogenic hepatic abscess. She was afebrile and denied any gastrointestinal symptoms other than anorexia. We discovered her hepatic abscess when we evaluated her for an occult malignancy as the cause of her anemia. She was treated with percutaneous drainage of her abscess and parenteral antibiotic therapy. We searched MEDLINE, a computerized database, to find other patients whose hepatic abscesses presented as anemia. Although mild anemia is a common accompaniment of pyogenic hepatic abscesses, we found no reports of patients who presented with fatigue and anemia without any of the more common symptoms of hepatic abscess, such as fever, right upper quadrant pain, malaise, or nausea. We conclude that anemia without fever or abdominal symptoms is a rare presentation of pyogenic hepatic abscess.
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PMID:Hepatic abscess presenting as severe fatigue and anemia. 827 88


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