ITS FIBROLAMALAR VARIENT OF HCC^-www.drkeyurbhatt.in*

70 yrs female with dull aching pain in RHC region no other positive symptoms...
On examination Huge liver Mass...

AFP & CEA LEVELS ARE NORMAL
LFT, CBC,RFT : ALL NORMAL...

ARTERIAL PHASE

PORTAL PHASE

DELAYED PHASE 

ANGIO RECONSTRUCTION 

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CASE: CONGENITAL DIAPHRAGMATIC HERNIA PRESENTED IN ADULTHOOD^-www.drkeyurbhatt.in*

Incidetaly detected Congenital diaphragmatic hernia......explained and Reassurance given....surgery is needed only in case of symptoms....

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CASE : Sad and Strange-- perforation in both Jejunal limbs of Previous J-J & LPJ done in 2008 for Chronic pancreatitis^-www.drkeyurbhatt.in*

Past history:
21 yrs boy with recurrent pain in abdomen...diagnosed as chronic pancreatitis and underwent Pustow's procedure in 2008, Eight days post op had acute obstruction and underwent re laparotomy...(Hydrabad)

remain okey for about  6 months ...than started developing recurrent episodes of pain in abdomen...all the time thought of sub acute obstruction / ? recurrent pancreatitis....became addict to Dynapar / Contromol...

developed acute intestinal obstruction...in Jan 2010...and once again was operated and adhesiolysis done....(mumbai)
again having multiple episodes of pains......was planned of Head corring and revision of surgery of Pancreas in Mumbai...admitted and evaluated for surgery but in view of malnutrition and low albumin deferred of surgery...and 1 month TPN given...and discharged to build up...

Again started of having pain ...got admitted...and thought of adhesions / ? pancreatitis...2-3 days treated conservatively....not responding to Rx and started more detoriating ....CECT was done....and it was peritonitis...
I got REF....and I had To Explore .....for the fourth time....and Oh My God....
he had 2.5 liters of peritonitis ...3 days old...already on Inotrops and low albumin..sepsis...
and Two perforations in both the limbs proximal of Previous J-J......horrible...just 1 feet from DJ...

WE SHOULD  RULE OUT ALL ORGANIC CAUSES BEFORE LABELING THAT PATIENT IS PSYCHOTIC....OR ADDICT TO ANY MEDICINE.................

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CASE: Grade IV liver Trauma (Once thought unsurvivable now .......Child Back to School......)^-www.drkeyurbhatt.in*

PAST HISTORY:

16 yrs boy with Blunt trauma abdomen --> liver laceration and hemoperitoneum (2 liters), hemodynamically unstable
Explored--> hemostasis tried....massive bleeding---packing done

remained on venti for 2 days...bleeding continue...>10 blood / products given...

PRESENTATION : Cont. bleeding even after packing..and Hemodynamic unstability (again more than 1.5 liter blood loss)

RE EXPLORED AFTER 48 hrs of previous surgery & hemostasis achieved...drains kept in Morrison's puch and pelvis.......gradually stabilized...Extubated after 6 critical  days....pelvic drain removed...started on Oral diet...

developed Biliary fistula from injured peripheral seg 7 of liver...Per cutaneous Malacot catheter placed in collection near seg 7...and drain removed....fistula localised.....discharged of hospital after 1 month stay...
ERC and stenting done...gradually fistula out put decreased.....unfortunately developed stent blockage and cholangitis...
Re admitted and stent changed with smaller caliber straight flap stent on Rt side...
External Fistula healed...and malacot removed....no residual collection....

Once thought unsurvivable now .......Child Back to School......

last MRI before episode of Cholangitis...
showing healing laceration and
compensatory hypertrophy of left lobe of Liver

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CASE: ANURSM LIGATED DOUBLY SURGICALLY...DELAYED HEMORRHAGE IN A CASE OF LIVER TRAUMA ? PSEUDOANURISM OF Rt hepatic artery^-www.drkeyurbhatt.in*

HISTORY:

30 YRS male
h/o fall and liver contusion/hematoma 26 days back in Rajasthan
USG : s/o no e/o free fluid and only liver hematoma.
Rx conservatively...........
remained well till 14 days ...sudden increase in pain----CECT was done : s/o 11 x10 cm size liver contusion
no free fluid....conservative Rx....in 3 days sudden fall in Hb. with gross haemoperitoneum, shock, anuria, and renal failure with Creat progressed to  6.2
Explored---- liver laceration and 2 liters of hemorrhage drained....no active bleeding....drains kept...Repair of laceration tried near GB fosa.

PRESENTATION :

post op pt remained stable...on day 2 developed biliary fistula draining frank bile in both drains later localized to sub hepatic drain 200 ml / day.

remained stable for 12 days and was walking / tolerating oral normal diet, normal urine out put with creat of 2.5

suddenly 2 liter of fresh bleeding in drain no hemoperitoneum. resucitation given again after 3 hrs massive bleeding of 2 liters....and hemoperitoneum as well.

DIAGNOSIS: Rt hepatic artery pseudo anurism was suspected...... as CECT/MRI OUT OF question in view of on going ARF and Pt in Shock....

Explored cholecystectomy and Rt hepatic artery ligated 1.5 liters of hemoperitoneum drained...and all bleeding secured...abdomen closed with drains and repair of liver laceration....IN HOPE OF STABILITY.....

now as expected pt is confirmed having Rt hepatic artery pseudoanurism...and the sad part is that anurism has now taken supply from left hepatic artery and is still getting filled.......its of 1 cm in size (quite big for a segmental hepatic branch..3 times bigger)....all radiological options are out of question in view of previous life saving attampt and ligation of RHA....will require formal resection / doubble ligation on both side of anurism surgically.....

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