CASE 738-739: OCCULT B INFECTION (OBI) and CIRRHOSIS and HCC, Dr PHAN THANH HẢI, Dr LÊ ĐÌNH VĨNH PHÚC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Case 738:

A man 54 year-old with fever for 4 days and epigastric pain.

Abdominal ultrasound detected a right lobe hepatic tumor # 12cm, but with negative infected HBV except value of AFP of 51.40 ng/mL. MSCT confirmed liver tumor.

:

Case 739:

A female nurse 56 year-old  with unknown cause of rising liver enzymes and HBsAg negative for 3 years. But HBV DNA positive  and AntiHBc total  positive at this time. Liver FibroScan F 3. Obstruction of branch of portal vein on MRI Primovist. Only cirrhosis and no sign of liver cancer. 

REFERENCE

CASES 735-736-737: ENHANCED MYOMETRIAL VASCULARITY [EMV], Dr PHAN THANH HẢI, Dr DƯƠNG ĐĂNG NGỌC PHƯƠNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM

3 cases of EMV post partum were discovered by Doppler ultrasound and were managed successfully in ceasing the menorrhagia by curettage.

Case 01:

After 3 months delivery without menorrhagia and beta HCG negative but EMV on transvaginal sonography (TVS). Doubtful placental retention.

Case 02:

Menorrhagia for 20 days after miscarriage, blood beta HCG = 19.25mUI/mL, TVS detected EMV.

Case 03: 

Menorrhagia in small amount for each batch every 2-3 days with  beta HCG highly rising = 66.975  mUI/mL, TVS detected uterine bloody retention, noted placental retention and EMV.

Microscopic specimen was placental villous structure.

BetaHCG = 2.1mUI/mL after curettage procedure.

REFERENCE

EMV Ultrasound findings ( from Radiopaeda)

It is impossible to distinguish enhanced myometrial vascularity from a true arteriovenous malformation on ultrasound 5. 

On greyscale ultrasound, there are anechoic, tortuous, tubular structures within the myometrium that may involve the endometrium. Echogenic intrauterine material in keeping with concurrent retained products of conception is commonly seen.

On color Doppler ultrasound, there is a mosaic turbulent pattern with multiple flow reversals. This demonstrates low impedance flow with a high peak systolic velocity (PSV) ≥20 cm/s and low arterial waveform pulsatility. It should be noted that while some authors consider a PSV >60 cm/s to be high risk 4,9,10, studies have shown that higher PSV values do not necessarily confer a greater hemorrhagic risk 1. 

CASES 732-733-734: SUBCLAVIAN ARTERY ANEURYSM, Dr PHAN THANH HẢI, Dr ĐINH MINH TUẤN, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

03 cases of SUBCLAVIAN ARTERY ANEURYSM [ 2 right, 1 left side] from 3 males 34-32-44 year-old revealed by chest X-Ray, vascular ultrasoud and MSCT. Patients complaint weakness upper limb, numbness and right chess pain or  just only for a check-up without symptoms.

Chest X-Rays noted a blurred node close by the clavicle which could not differentiate from anterior mediastinal tumor or lung tumor. Vascular ultrasound could detect a yin-yang sign of a round mass with thrombus of the wall and MSCT could determine exactly the size, location, and reconstruct in 3D view.

CASE  01

Male patient 34 year-old for check-up. A 69 round mass was on the left clavicle. Yin-yang sign positive and thickening wall due to thrombus on ultrasound. The left brachial artery was intact.

CASE 2

Male patient 34 year-old with cough and chest pain. The subclavian aneurysm size was # 49x52 mm with calcified its wall on chest X-ray. Thrombus of the aneurysmal wall on ultrasound and MSCT. Turbulent flow on Doppler vascular ultrasound. 

CASE  3

Male patient 44 year-old weakness right upper limb, hoarseness and chest pain. The subclavian aneurysm was # 10×8 mm with turbulent flow, and thrombus filled up nearly the lumen. 3D view of MSCT reconstruction was not seen the aneurysmal lumen.

Surgery repaired the subclavian aneurysm with Y unigraft and the patient remains well. The aneurysm with its calcified contour was seen on the post-op chest X-ray.

CASES 730-731: SECONDARY APPENDICITIS in ELDERLY PATIENTS, Dr PHAN THANH HẢI, Dr PHẠM THỊ THANH XUÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

There are two instances of secondary inflamed appendices in senior patients that might make for intriguing clinical notes.

Case 01.

A 78 year-old man with RLQ colicky pain for one month and loose stool. Ultrasound detected an appendiceal lump with a big appendix which was #69x17mm containing mixed fluid. The cecum was uncertainty a tumoral mass #72×48mm with air inside. Sonologist noted a rupture of appendiceal mucocele which made an appendiceal lump unveiled the cecum. 

But MSCT noted an inflamed cecum as edema of the cecum wall and a fluid-filled appendix as appendiceal mucocele.

Report of surgery was cecum cancer and a dilated acute appendicitis.

Case 02:

A 78 year-old  man with acute RLQ pain.

Ultrasound detected a #38mm cecum cancer which caused dilated appendicitis. Later MSCT confirmed the cecum cancer and the appendicitis which was compressed by the colon tumor.

The right colon tumor and the nearby appendix filled with fluid were discovered during surgery.

DISCUSSION 

Appendicitis seldom develops in senior patients above the age of 70. This might be because the appendix's tip and the colon's lymph tissue were underdeveloped.

The issue of appendix blockage brought on by colon tumor compression may be explained by the two appendicitis instances with colon cancer mentioned above.

Given that the etiology of appendicitis remains uncertain, it is important to reveal the presence of colon cancer in older patients.

CASES 727-728-729: SUBCLINICAL ABDOMINAL AORTIC ANEURYSM, Dr PHAN THANH HẢI, Dr TRẦN MỘC HIỆP, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 3 cases (1 female,  2 males ) with subclinical abdominal aortic aneurysm [AAA] were incidentally detected firstly by abdominal ultrasound, and confirmed later by MSCT. 

Surgery repaired abdominal aorta with Y tube silver graft and all of patients were well post-op.

Case one: 

A 61 year-old man with hematemesis, normal BP: 120/80 mmHg, but  gets hypogastric pain. AAA # 60x90 mm from renal artery level to iliac artery.

Case 02:

A 71 year- old woman with lordosis for a check-up,  BP :125/80 mmHg. AAA # 60X103 mm from renal artery level in risk of rupture, and iliac artery aneurysms.

Case 03:

A 78 year-old man with sleep trouble, BP :124/79 mmHg. AAA# 40x70 mm and iliac artery aneurysm.

DISCUSSIONS:

Elderly patients complaining of lumbago, lower limb weakness, erectile problems in males, or occasionally feeling of "a heart in the abdomen" may have a silent abdominal aortic aneurysm. 

In our facility, the annual incidence of subclinical abdominal aortic aneurysm is around 10%. Additionally, the AAA dissection may occur in 10% of those AAA.

In Vietnam, applying ultrasound first, POCUS in particular, may be useful in identifying the AAA (and then MSCT to confirm) that helps preventing the elderly patient's death. Sonologists should make it a practice to check for abdominal aortic aneurysms before concluding the ultrasound examination.

REFERENCE:

Nguyễn Thiện Hùng, Phan Thanh Hải et al (1998): Ultrasound for diagnosing abdominal aortic aneurysm and prognosis in 10 years, Journal of Medicine Practice of Medicine and Pharmacy Society in HCM City:3:pp 3-7.

CASE 726: BOWEL TUMOR, Dr PHAN THANH HẢI, Dr PHAM THỊ THANH XUÂN, MEDIC MEDICAL CENTER, HCMC,

 A 55 year-old woman with anemia and dark stool complained epigastric and subcostal pain for one year.

Ultrasound detected a bowel tumor # 20-40mm above aorta, hypoechoic without vascular signals maybe bowel GIST. 

MSCT confirmed  a #20×43 mm bowel GIST.

Surgery removed the tumor. Histopathological result is GIST (spindle cell tumor).

DISCUSSIONS 

GIST of the GI tract can be found by ultrasound, particularly from the bowel wall. Three cases from the bowel—one from the rectum, one from the stomach—are being revealed at Medic Center.

However, using chemohistopathological staining and histopathological results, MSCT plays a crucial role in the diagnosis of GIST of gastrointestinal tract.

CASE 725: INFECTED HBV and HCC, Dr PHAN THANH HẢI, Dr HỒ TẤN ĐẠT, MEDIC MEDICAL CENTER, HCMC , VIETNAM

A 53-year-old man who had been infected with HBV since 2011 arrived at Medic Center because of rumors that he had liver cirrhosis, but he refuses any knowledge of illness. 

Ultrasound detected  a # 30 mm liver tumor in the left lobe and in caudate lobe of the liver and F4 on Fibroscan while his clinical status is almost nothing abnormal detected.

 

 

Lab data noted  a HCC high risk (WAKO test).

MSCT confirmed liver tumors and chronic hepatitis

 

The man died in hospital 6 months later. 

DISCUSSIONS:

 

HBV infection causes liver cancers which are highly prevalence in Vietnam.

In HCM city the seroprevalence of HBV is still high, ranging from 8 to 13 percent. On the other hand, 70% HBV patients have no symptoms which may develop the liver cancer at a later stage.

It must be identified the  infected HBV cases in the community as soon as feasible and the family members must get care and vaccination. Patients with HBV infection require monitoring every three to six months for detection liver cancer  in order to treat them quickly and save them from dying.