Low phospholipid-associated cholelithiasis syndrome:A rare cause of acute pancreatitis that should not be neglected

BACKGROUND Low phospholipid-associated cholelithiasis(LPAC)syndrome is a very particular form of biliary lithiasis with no excess of cholesterol secretion into bile,but a decrease in phosphatidylcholine secretion,which is responsible for stones forming not only in the gallbladder,but also in the liver.LPAC syndrome may be underreported due to a lack of testing resulting from insufficient awareness among clinicians.AIM To describe the clinical and radiological characteristics of patients with LPAC syndrome to better identify and diagnose the disease.METHODS We prospectively evaluated all patients aged over 18 years old who were consulted or hospitalized in two hospitals in Paris,France(Bichat University Hospital and Croix-Saint-Simon Hospital)between January 1,2017 and August 31,2018.All patients whose profiles led to a clinical suspicion of LPAC syndrome underwent a liver ultrasound examination performed by an experienced radiologist to confirm the diagnosis of LPAC syndrome.Twenty-four patients were selected.Data about the patients’general characteristics,their medical history,their symptoms,and their blood tests results were collected during both their initial hospitalization and follow-up.Cytolysis and cholestasis were expressed compared to the normal values(N)of serum aspartate and alanine transaminase activities,and to the normal value of alkaline phosphatase level,respectively.The subjects were systematically reevaluated and asked about their symptoms 6 mo after inclusion in the study through an in-person medical appointment or phone call.Genetic testing was not performed systematically,but according to the decision of each physician.RESULTS Most patients were young(median age of 37 years),male(58%),and not overweight(median body mass index was 24).Many had a personal history of acute pancreatitis(54%)or cholecystectomy(42%),and a family history of gallstones in first-degree relatives(30%).LPAC syndrome was identified primarily in patients with recurring biliary pain(88%)or after a new episode of acute pancreatitis(38%).When present,cytolysis and cholestasis were not severe(2.8N and 1.7N,respectively)and disappeared quickly.Interestingly,four patients from the same family were diagnosed with LPAC syndrome.At ultrasound examination,the most frequent findings in intrahepatic bile ducts were comet-tail artifacts(96%),microlithiasis(83%),and acoustic shadows(71%).Computed tomography scans and magnetic resonance imaging were performed on 15 and three patients,respectively,but microlithiasis was not detected.Complications of LPAC syndrome required hospitalizing 18 patients(75%)in a conventional care unit for a mean duration of 6.8 d.None of them died.Treatment with ursodeoxycholic acid(UDCA)was effective and well-tolerated in almost all patients(94%)with a rapid onset of action(3.4 wk).Twelve patients’(67%)adherence to UDCA treatment was considered“good.”Five patients(36%)underwent cholecystectomy(three of them were treated both by UDCA and cholecystectomy).Despite UDCA efficacy,biliary pain recurred in five patients(28%),three of whom adhered well to treatment guidelines.CONCLUSION LPAC syndrome is easy to diagnose and treat;therefore,it should no longer be overlooked.To increase its detection rate,all patients who experience recurrent biliary symptoms following an episode of acute pancreatitis should undergo an ultrasound examination performed by a radiologist with knowledge of the disease.

A vaginal drain of a pelvic abscess due to colonic diverticulitis

Although well recognized for tubo-ovarian abscesses, we report, in our best knowledge, the first case of a vaginal drain of a pelvic abscess due to colonic diverticulitis. A 78-year-old patient presented with abdominal and pelvic pain, fever(39.3 ℃) and an elevated white blood cell count(18500/mL). After abdominopelvic computed tomography the patient was presumed to have a pelvic abscess, which developed as a complication of the sigmoid diverticulitis. Due to the numerous intervening structures that create obstacles to safe percutaneous access, we planned a trans-vaginal drain. A rapid recovery was obtained within 2 d from the procedure and, at present, the follow-up was uneventful after 18 mo. We believe that transvaginal drain of pelvic abscess could be a useful alternative, when percutaneous approach is not feasible.

Knowledge of Togolese Doctors on Biological Effects of Ultrasound and Their Attitudes towards the Ultrasonographic Explorations Performed in Lome (Togo)

We evaluate the level of knowledge of clinician doctors asking for echographies on the biological effects of ultrasounds and their attitudes towards ultrasounds examinations performed in Lome. Transverse study based on a survey led from August 16th till November 30th, 2013 including 105 doctors applicant of ultrasound in Lome (Togo). The middle age of the applicant doctors was of 34 years with a sex-ratio of 4/1 and more than half practiced in public facilities. Approximately ten percent applicants thought that the ultrasound is an irradiant exam and those practicing for less than 5 years were the ones who had a good level of knowledge on the not irradiant character of the ultrasounds. The existence of the thermal and mechanical effects of the ultrasounds was known only by 4.8% of the applicants and only 1.9% of the doctors had information on the thermal index (TI) and the mechanical index (MI). More than half (66.7%) analyzed the ultrasound images joined to the report but none verified the conformity with the standards of the values of the TI and at MI shown on the images. They were 43.5% to read only the conclusion. The level of knowledge of the doctors on the biological effects of the ultrasounds is unsatisfactory. The ultrasounds although not irradiant, have biological effects imposing precautionary measures which have to guide the attitude of the applicants towards the ultrasonographic explorations.

Granulomatous Mastitis, Radio-Histological Correlation

Granulomatous mastitis, also called granulomatous lobular mastitis, is a benign pathology of the mammary gland characterized by chronic inflammation of the gland tissue, which becomes erythematous, manifesting itself as a palpable and painful mass on physical examination, sometimes it can be accompanied by abscesses. The following case is a 45-year-old Guatemalan female, with a history of increased volume in the left breast, compromising the upper quadrants. A mammogram was performed, followed by breast ultrasound;the diagnosis was confirmed by histology. The treatment offered was surgery with image controls every six months.

Physical Stress Echocardiography Evaluation in Athletes with Bicuspid Aortic Valves

Objective: Bicuspid Aortic Valve (BAV) is normally asymptomatic for a long time in both the general population and regularlytrained athletes. The study aimed to evaluate the role of physical stress echocardiography in early identification of any possible dissimilarities in the Left Ventricle (LV) performance and the valve functioning of asymptomatic BAV athletes as compared to the Tricuspid Aortic Valve (TAV) athletes. Design: Data were collected for BAV and TAV athletes from echocardographic examinations to evaluate any possible differences between them. Setting: Sport Medicine Center University of FlorenceItaly. Participants: 66 male BAV athletes and 45 TAV athletes Assessment of risk factors: decrease in LV performance and aortic valve dysfunction during stress test. Main outcome measures: Measure of the standard echocardiographic parameters. Comparison of LV Ejection Fraction (EF) and Aortic Peak Flow Velocity (APFV) data in the two groups at rest and after stress. Results: At rest, values were normal in both groups, although LV systolic diameters tended to be higher in BAV. After physical effort, APFV and EF showed a significant increase in both groups, and for the former the values were at the upper limits in BAV (2.55 m/s BAV 2.12 m/s TAV). Conclusions: The data confirm normal LV performance in asymptomatic BAV athletes. Considering the tendency of this group to show slight enhancement of both APFV and LV dimensions in this group periodical evaluation with physical stress echography might be proposed as a followup procedure for early detection of any additional effect of physical exercise.