RESUMEN
The Fibrolamellar variant of Hepatocellular Carcinoma (FLHCC) is a rare form of liver cancer that presents in the 3rd decade of life, is rarely associated with cirrhosis or chronic Hepatitis B/C virus infection, and usually presents with normal serum alpha-fetoprotein (AFP) levels. FLHCC presenting during pregnancy is extremely rare, with only 4 cases reported. We present a case of FLHCC in pregnancy and discuss the dilemmas in management. A 26 year-old primigravida, 26 weeks of gestation presented with a month's history of obstructive jaundice secondary. Investigations revealed a mass in the left lateral segment of the liver with extension down the left hepatic duct into the common bile duct. Following an emergency caesarean section at 31 weeks, she underwent a left hepatectomy with extrahepatic bile duct excision. The postoperative course was uneventful. Histopathology showed FLHCC. In conclusion, liver tumors presenting during pregnancy should be managed in a multidisciplinary setup with facilities for neonatal intensive care. Management depends on the presumed pathology, period of gestation and family preferences.
RESUMEN
INTRODUCTION: Patients with Acute Pancreatitis (AP) presenting with Systemic Inflammatory Response syndrome (SIRS) are more likely to have severe acute pancreatitis and are at increased risk of complications. Additionally, persistence of SIRS at 48 hrs after admission is associated with persistent organ failure and a worse outcome. We investigated the usefulness of SIRS as a criterion for referring patients to a tertiary pancreatic care centre. MATERIAL AND METHODS: Retrospective analyses of patients admitted with AP over a one year period. Patients were classified into 2 severity groups - 1) Mild AP, 2) Moderate and Severe AP (MASP) as per the Revised Atlanta Classification. SIRS was determined at presentation and following 48 hours of best medical management. Outcomes were compared between patients who had no SIRS at presentation, transient SIRS(SIRS≤48hrs) and persistent SIRS(>48hrs). RESULTS: 134 patients were included in the study. SIRS at presentation had a sensitivity of 88%(95% CI 75-96) and a specificity of 66%(95% CI 55-75) in predicting MASP. However, persistent SIRS and recovery from SIRS within 48hrs were poor predictors of MASP. Only 23/43 (53.5%) patients with MASP had persistent SIRS. Interestingly, MASP patients with persistant SIRS had a significant higher risk of complications, readmission, intervention, culture positivity and hospital stay as compared to those with transient SIRS. CONCLUSION: Persistent SIRS could be used to identify patients with MASP requiring tertiary care. This could be used as an effective tool by community hospitals with limited facilities. Further, prospective studies are required to validate our findings.
Asunto(s)
Pancreatitis , Síndrome de Respuesta Inflamatoria Sistémica , Enfermedad Aguda , Adulto , Femenino , Humanos , India/epidemiología , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud/métodos , Evaluación de Resultado en la Atención de Salud/normas , Pancreatitis/complicaciones , Pancreatitis/diagnóstico , Pancreatitis/epidemiología , Readmisión del Paciente/estadística & datos numéricos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Evaluación de Síntomas/métodos , Evaluación de Síntomas/normas , Síndrome de Respuesta Inflamatoria Sistémica/diagnóstico , Síndrome de Respuesta Inflamatoria Sistémica/etiología , Síndrome de Respuesta Inflamatoria Sistémica/fisiopatología , Atención Terciaria de Salud/organización & administraciónRESUMEN
Guidelines for the management of acute pancreatitis (AP) are based on the Western experience, which may be difficult to extrapolate in India due to socioeconomic constraints. Hence, modifications based on the available resources and referral patterns should be introduced so as to ensure appropriate care. We reviewed the current literature on the management of AP available in English on Medline and proposed guidelines locally applicable. Patients of AP presenting with systemic inflammatory response syndrome are at risk of moderate-severe pancreatitis and hence, should be referred to a tertiary center early. The vast majority of patients with AP have mild disease and can be managed at smaller centers. Early aggressive fluid resuscitation with controlled fluid expansion, early enteral nutrition, and culture-directed antibiotics improve outcomes in AP. Infected pancreatic necrosis should be managed in a tertiary care hospital within a multidisciplinary setup. The "step up" approach involving antibiotics, percutaneous drainage, and minimally invasive necrosectomy instituted sequentially based on clinical response has improved the outcomes in this subgroup of patients.