EMQs in Clinical Medicine.pdf - Peshawar Medical College

Liver diseases – answers 169
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A 35-year-old woman is worried about an abdominal mass that has
grown over the last 6 months and a similar length history of very
heavy menstrual bleeding with no intermenstrual bleeding. On examination
a knobbly mass can be felt in the middle lower quadrant that is
dull to percussion. The lower edge is not palpable. She is otherwise well.
Fibroids are the commonly used name for fibromyomas, which are
benign tumours of uterine smooth muscle. The incidence of fibroids
increases with age.
Patients typically present with symptoms of increased menstrual blood
loss in middle-aged women. Other common presentations include infertility
and symptoms caused by pressure on other structures, e.g. urinary
frequency, constipation. Fibroids vary considerably in size and may grow
such that they occupy a large part of the abdomen and compress other
structures. A patient may also present with an acute abdomen after
thrombosis of a fibroid’s blood supply (red degeneration).
Management depends on several factors, including the size of the
fibroids, symptoms, patient’s circumstances, etc. Surgical interventions
include myomectomy, uterine artery embolism and hysterectomy.
Fibroids are oestrogen dependent and gonadotrophin analogues are
sometimes given to shrink fibroids before surgery.
A 70 year old with alcohol problems presents with a tender upper
abdominal mass. CT shows a thick-walled, rounded, fluid-filled mass
adjacent to the pancreas.
Pancreatic pseudocysts are usually located in the lesser sac adjacent to
the pancreas. They occur as a result of ductal leakage after inflammation
of the pancreas (acute or chronic). Chronic pancreatitis is the most common
cause of pancreatic pseudocyst. These patients may present nonspecifically
with abdominal discomfort, nausea, early satiety, etc.
Complications of pancreatic pseudocyst include infection (most common),
obstruction (of common bile duct leading to jaundice) and
perforation. Very rarely the pseudocyst can enlarge such that it erodes
nearby vessels, causing pseudoaneurysm formation that can be fatal.
Fortunately, most pseudocysts resolve spontaneously.
CT is the investigation of choice and typically shows a round/ovoid
fluid-filled cavity encapsulated by a fibrous wall. A pseudocyst does not
have a true epithelial lining. Pancreatic pseudocysts can be treated by
drainage if it is felt that there is a high risk of complication.
57 Liver diseases
Answers: A K E H D
A 69-year-old retired bricklayer presents with weight loss, fever and
right upper quadrant pain. On examination, a hard, irregular liver can
be felt on palpation. Serum AFP is grossly elevated.