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CASE PRESENTATION: A 61-year-old female was referred to our hospital with a neoplastic lesion in the duodenum. Computed tomography with contrast enhancement revealed a 10-mm tumor in the duodenum. Upper gastrointestinal endoscopy revealed a submucosal tumor-like lesion in the descending part of the duodenum. Endoscopic ultrasound revealed a well-defined hypoechoic tumor. Biopsy and immunohistochemical findings including negative Synaptophysin and Chromogranin A staining and positive Trypsin and BCL10 staining suggested a carcinoma with acinar cell differentiation. Pancreatoduodenectomy was performed, and the resected specimen had a 15-mm solid nodule in the submucosal layer of the duodenum. Pancreatogram of the resected specimen revealed a tumor localized in the accessory papilla region. In histopathological examination, the tumor was found in the submucosa of the duodenum with pancreatic tissue present nearby, and these were separated from the pancreatic parenchyma by the duodenal muscle layer. These findings led to a diagnosis of acinar cell carcinoma originating from the accessory papilla of the duodenum. CONCLUSION: Acinar cell carcinoma originating from the accessory papilla of the duodenum is exceptionally rare, with no reported cases to date. The origin was considered to be pancreatic tissue located in the accessory papilla region.

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Nivolumab induces several immune-related adverse events. Isolated adrenocorticotropic hormone(ACTH)deficiency has low frequency. A 73-year-old woman with gastric cancer metastasis of the peritoneum was treated with nivolumab as the third-line chemotherapy. After 5 courses of nivolumab, she developed hypothyroidism. After completing 12 courses, peritoneal metastasis increased. We evaluated the metastasis as progression of disease, so treatment with nivolumab was discontinued. Two weeks after the last dosage of nivolumab, she developed general fatigue and appetite loss. At first, we considered that these symptoms were caused by peritoneal metastasis, but progression was not indicated in the CT. Blood levels of cortisol and ACTH were very low. We suspected secondary adrenocortical insufficiency induced by nivolumab. Endocrinological examinations and the results of brain MRIsuggested isolated ACTH deficiency. This is the first report of isolated ACTH deficiency induced by nivolumab in a patient with gastric cancer metastasis of the peritoneum. The symptoms of adrenocortical insufficiency induced by nivolumab overlap with those of peritoneal metastasis, and thus, it may be difficult to confirm a differential diagnosis. When adrenocortical insufficiency is suspected, we should check the blood levels of cortisol and ACTH.

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Los autores estudiaron al azar por medio de manometría anorectal y serie gastrointestinal a 28 pacientes, de Santa María Ixhuatán, Depto. de San Rosa, Guatemala (área endémica de Chagas) dividido en 3 grupos: Grupo A: 5 pacientes seropositivos para Chagas más estreñimiento. Grupo B: 10 pacientes seropositivos para Chagas sin estreñimiento y, Grupo C: 13 pacientes seronegativos. Los resultados de la manometría anorectal de los 3 grupos fueron estadísticamente analizados por método descriptivo, con la prueba Kruskal-Wallis y gráficas de cajas de Tukey, verificándose que no había diferencia significativa entre los hallazgos de los 3 grupos,así como también no se verificó la presencia de megaesófago, ni megacolon en los pacientes estudiados, como hallazgo curioso en 4 de 5 pacientes el grupo A se comprobó radiológicamente: Ptosis gástrica que aparentemente no tiene relación con Enfermedad de Chagas

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It is generally that the gastrointestinal manifestation from Chagas disease in Central America is very rare. But this thesis is not fully evidenced with sofisticated inveestigation. In order to determine this thesis,an investigation focused on the gastro-intestinal tract by electro-manometry and X-ray was performed.

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