PubMed · 8539149
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S Price. Obstetric cholestasis.. https://pubmed.ncbi.nlm.nih.gov/8539149/
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The differential diagnosis of fever of unknown origin includes infectious diseases, malignancies and connective tissue diseases. Multiple myeloma is not usually included in the differential diagnosis, nor is it considered a frequent cause of cholestasis in the absence of amyloidosis. We report a case of multiple myeloma in a patient presenting with a long-standing fever and cholestasis. The patient underwent a long and unfruitful series of diagnostic procedures, including liver biopsy. The clue to the diagnosis, established with a marrow biopsy, was the presence of a paraprotein in the serum.
BACKGROUND: Heterotopic pancreas appears in 0.5 to 13% of autopsies. The most frequent locations are stomach, duodenum or upper jejunum. Pancreatitis in heterotopic pancreas is rarely described, and clinical symptoms caused by this heterotopic inflammation are uncommon. METHOD: We report a case of heterotopic pancreatitis localized in the major duodenal papilla causing biliary obstruction and mimicking a pancreatic head tumor. Clinically and radiologically, malignancy was suspected. Preoperative biopsies showed only fibrosis. A pylorus preserving resection of the pancreatic head was performed followed by an uneventful postoperative course. RESULT: Macroscopically, in the periampullary region on the pancreatic side a thickened duodenal wall with multiple lobules and cysts was found, compressing the common bile duct. Microscopic examination showed heterotopic pancreas with inflammatory lesions surrounding the ampulla. In the orthotopic pancreas a diffuse chronic pancreatitis with marked inflammation, fibrosis and atrophy of exocrine tissue was found. CONCLUSION: In our case it was impossible to differentiate between chronic pancreatitis and pancreas carcinoma preoperatively. Radiological findings and endoscopic biopsies were not sufficient to distinguish heterotopic pancreatitis from other tumors of the pancreatic head. Clear diagnosis could only be made by complete histological examinations after pancreatic head resection, being the treatment of choice for pancreatic head tumors of unclear dignity. The differential diagnosis of heterotopic pancreatitis as trigger of unclear enlargement of the pancreatic head is very seldom.
Gastrointestinal endoscopy offers a variety of methods for palliative treatment of tumor symptoms, most importantly self-expanding metal stents. Stent insertion achieves effective recanalisation of malignant stenoses in various locations of the gastrointestinal tract. This tutorial paper briefly reviews some of these methods. Special consideration is given to a number of practical points regarding patient follow-up by the general practitioner.