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| Case of the Week Thursday 14/2/2006 |
Presented by Dr. Aisha Mahmoud.
Haemangioma
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Staff round presentation
Prof.Dr. Gamal Esmat
Ass Prof.Hasan El Garem
Ass prof.Maissa El Razky
Dr.Mohamed Ibrahim
Dr.Ahmed Foad
Dr.Wafaa Elakel
Ass Lecture.Yasmin Saad
Ass Lecture. Dina Ismail
Dr. Mohamed Hamed
Dr. Mohamed Abdel hafez
By
Resident Dr.Aisha Mahmoud
Personal history:
A female patient, N. A. N , 40 years old, married 20 years ago, having 4 offsprings, the youngest 12years.
She is a housewife, she was born in Assiut but 3 years ago, she moved to Helwan .
There is history of contact with canal water but she didn ’ t receive antischistosomal treatment.
Menarche at the age of 13 with history of regular cycles.
History of using several methods of contraception: oral contraceptive pills 11 years ago for one year followed by hormonal injection for one year and lastly IUD which was removed after an attack of vaginal bleeding, 9 years ago.
Complaint:
Abdominal distention.
Present history:
The condition started 8 years ago by gradual onset & progressive course of abdominal distention which was not associated with lower limb edema, no abdominal pain, no fever and with normal bowel habits.
However the patient experienced an attack of hematemesis at the onset of the condition, about one cup of fresh blood, not associated with melena or disturbed conscious level ,for which she sought medical advice and upper endoscopy was done to her which revealed mild gastritis.
During this 8 years ,the abdominal distension was progressively increasing with loss of weight during the last 3 years.
Nine months ago, the patient developed cough, expectoration of white sputum, small in amount, not related to posture with dyspnea on the second floor but no orthopnea , PND or hemoptysis.
No urological symptoms.
No musculoskeletal or neurological symptoms.
Past history:
No history of T.B or admission to fever hospital.
The patient is not known to be diabetic or hypertensive.
No history of blood transfusion.
No history of operations.
No history of drug intake.
Family history:
No similar condition .
-ve consanguinity.
No family history of T.B.
Summary
A female patient, 40 years old complaining of abdominal distension 8 years ago, loss of wt 3 years, recurrent attacks of productive cough during last 9 months.
General examination:
The patient is fully conscious, co-operative, average intelligence & well oriented to time, place & persons.
-She is lying comfortable in bed.
-She is underweight.
-Pulse:80/min.
-Temp: 37 ° C .
-BP: 120/80
No pallor.
No cyanosis & no jaundice.
No thyroid swelling & no lymphadenopathy.
No congested neck veins
Upper limb :
No pallor.
No ecchymotic patches at site of injections.
No clubbing.
Lower limbs : No lower limbs oedema.
Abdominal examination:
Inspection:
Generalized abdominal distension with bossy appearance and full flanks.
No divarication of recti.
Wide subcostal angle.
Umbilicus shifted down and everted.
Ecchymotic patch at RT hypochondrium.
No scars, no abdominal wall veins, no hernias
Superficial palpation:
No abdominal tenderness.
There is a large abdominal mass felt in all quadrants of the abdomen except the RT iliac and lower suprapubic quadrants.
Deep palpation:
Liver:
Upper border: 7th space MCL.
The abdomen is occupied by a mass which is inseparable from the lower border of the liver.
-site: in all quadrants of the abdomen except RT iliac and lower suprapubic quadrants.
-size: 16 cm below RT costal margin, 30cm below xiphisternal junction with a transverse diameter of 40 cm.
-soft to firm in consistency, with rounded edge and bossy surface.
-Auscultation revealed no bruit or rub.
Spleen:
not felt and traubs area resonant.
No ascites detected in the suprapubic area.
Cardiac examination:
Free.
Chest examination:
Inspection: Free
Palpation: Free
Percussion: Free
Auscultation:
-Vesicular breathing with prolonged expiration.
- generalized inspiratory and expiratory rhonchi.
Neurological examination
- Clinically free
URINALYSIS
Protien: Nil.
Glucose: Nil.
Bile pigment : Nil.
Pus cells: 1-2/HPF
No RBCs, casts, crystals or ova.
Stool analysis
Free
CBC
RBCs: 3.3 million
HGB: 10.1gm%
MCV: 87 fl.
MCH: 30 pg.
MCHC: 34 g/dl.
PLT: 350,000.
ESR (after correction)
1st hour: 13 mm
2nd hour: 29 mm
Liver biochemical profile
BIL T: 0.9 mg/dl (0.2-1.2)
AST: 15 u/l (0-41)
ALT: 6 u/l (0-41)
TOTAL POTEINS: 7.7 g/dl. (6.4-8.3)
ALBUMIN: 4g/dl (3.5-5)
ALP: 87 u/l (35-104)
PT : 15 sec
PC: 70%
RENAL FUNCTIONS
Urea: 41 mg/dl (10-50)
Creatinine: 0.6 mg/dl (0.7-1.3)
FBS: 90
2 hours post prandial blood sugar: 110
ABDOMINAL U/S:
Liver: Averaged sized right lobe with homogenous ecchopattern. The right lobe is displaced downward by a large hyperechoic well defined mass measuring 19*13 cm. The left lobe is compressed by a huge mass reaching the left iliac fossa with heterogenous eccopattern with cystic areas and lobulated at the lower part .No IHBRD Portal vein is not dilated and patent.
G.B : average in size & wall thickness with a small 3 mm single calculus . CBD is not dilated.
Spleen: average in size ,homogenous ecchopattern,longest axis 9 cm.
Kidney : average in size, parenchymal echogenecity, no typical calculi or back pressure changes.No suprarenal masses
Pancreas: Free
IVC and aorta are mildly compressed by the mass and displaced medially but patent with average flow
Upper endoscopy
2 small upper oesophageal venous blebs.
Small sliding hiatus hernia.
Mild congestive gastropathy at the body and fundus of the stomach.
External gastric compression.
C.T chest,abdomen and pelvic
The chest revealed scattered areas of bronchiectatic changes and peribronchial thickening are seen in the medial segment of the right middle lobe and posterior segment of the left lower lobe.
Normal C.T appearance of the great vessels and heart.
No pleural or pericardial collection and no enlarged hilar or mediastinal L.N.
The liver is markedly enlarged crossing to the left hypochondreal region with the presence of huge hypodense mass lesion occupying the whole left hepatic lobe, two other mass lesions are seen involving the right hepatic lobe.the mass lesions are inseparable from each other with same hypodensity texture and peripheral irregular enhancement .No dilated biliary radicles.Portal vein is demonstrated at porta hepatis and its right branch.
Normal appearance of spleen,both kidneys and pancreas which are all compressed by the enlarged mass.
No ascites or lymphadenopathy.
Normal appearance of the pelvic organs.
Conclusion:
Hepatomegaly with multiple liver masses likely neoplastic for biopsy.
Bronchiectasis in the medial segment of the right middle lobe and posterior segment of the left lower lobe.
Pathology
Gross: needle core biopsy specimen 1 cm .
Microscopic: revealed benign lesion compossed of variable sized blood spaces lined by endothelial cells with focal cystic changes showing frequently intraluminal RBCs with intervening connective tissue showing heterogenous fibrosis. No liver tissue was encounterd in all examined serial sections.
Conclusion:
needle core biopsy from a case of large abdominal mass
Cavernous haemangioma .
Doppler
Normal arterial and venous duplex of both lower limbs and abdominal vessels.
Echocardiography
Normal RT atrim, RT ventricle, LT atrium, and LT ventricle.
The contrast material filled the right atrium and right ventricle and did not appear in the left side.
Intact cardiac septa
No intracardiac masses, no thrombi and no pericardial effusion.
Thank you
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