Among pancreatic cystic lesions, mucinous cystic neoplasm (MCN) and intraductal papillary mucinous neoplasm (IPMN) of the pancreas are precursor lesions of pancreatic adenocarcinoma. IPMN is characterized by intraductal papillary proliferation of mucin-producing epithelial cells that exhibit various degrees of dysplasia. IPMN is classified as the main duct type (MD-IPMN), mixed type and the branch duct type (BD-IPMN) according to the location of involvement, and into four histological subtypes (gastric, intestinal, pancreatobiliary, and oncocytic) according to the histomorphological and immunohistochemical characteristics. Most patients with MD-IPMN undergo tumor resection due to moderate to high risk of malignancy. Patients with BD-IPMN who do not undergo resection may develop malignant change, and concomitant separate pancreatic cancer occurs in 2-10% of patients with IPMN. Patients with BD-IPMN who do not undergo resection should do careful surveillance including endoscopic ultrasound sonography for the early detection of malignant change and separate pancreatic cancer.
Physiological changes caused by pregnancy promote the formation of gallstones, increasing the risk of acute cholecystitis, cholangitis, and cholelithiasis that occur during pregnancy. Since these diseases can be fatal to both mother and fetus, active treatment is critical. Biliary gallstones are preferably treated using endoscopic retrograde cholangiopancreatography (ERCP), even during pregnancy. While there is no alternative, safer and easier treatment method, complications from ERCP are lethal; therefore, several risks and benefits must be considered. First, various tests should be conducted and considered to determine whether ERCP is necessary. The risk of congenital disabilities from radiation exposure to the fetus during ERCP should be considered and minimized. Furthermore, clinicians should be aware of and use safe anesthetic agents and antibiotics that are safe to use during pregnancy. Finally, ERCPists should be familiar with various technical methods, such as the recently introduced ERCP technique without radiation exposure, stent drainage without complete removal of gallstones in the case of large biliary stones, and removal of biliary stones after childbirth. Pregnancy is not a contraindication for ERCP; as a lifesaving procedure, it should be performed when necessary. Even though the safety of ERCP is considered an acceptable risk in pregnancy, clinicians should continue to try and find safer ways for pregnant women and fetuses being treated for cholelithiasis.
Sarcomatoid carcinoma is rarely diagnosed as gallbladder cancer. Its aggressive nature, due to the characteristics of both sarcoma and carcinoma, results in a poor prognosis. We report a case of gallbladder sarcomatoid carcinoma in an 82-year-old male who was referred to our hospital for evaluation of gallbladder cancer observed on abdominopelvic computed tomography. The characteristics of the cancer were not confirmed after several imaging modalities. The surgically resected tumor was positive for both cytokeratin and vimentin as revealed via immunohistochemical staining, and a sarcomatoid carcinoma was finally diagnosed. The role of chemotherapy has not yet been identified. Therefore, radiation therapy is planned to reduce the risk of recurrence.
Lactococcus garvieae is a Gram-positive cocci that has been known to be a fish pathogen, and considered as a low virulence organism rarely associated with human infection. We report a case of acute cholangitis with common bile duct (CBD) stone and bacteremia by L. garvieae bacteremia in a 70-year-old male. The patient presented with epigastric pain and was diagnosed with two CBD stones. Blood culture obtained prior to empiric antimicrobial therapy with ceftizoxime sodium showed growth with Escherichia coli and L. garvieae. The bacteria were confirmed by matrix-assisted desorption/ionization time-of-flight mass spectrometry. Initial attempt at endoscopic biliary drainage failed, and the patient underwent percutaneous transhepatic biliary drainage and subsequent stone removal. He occasionally ingested raw fish and had a history of gastric ulcer with acid suppression therapy, which could be possible risk factors for L. garvieae infection. This is the first case of L. garvieae bacteremia in acute cholangitis.