- 7 yr MI Lab Ret presented for inappetance and vomiting on 7/16/2020. Diagnosed w/ pancreatitis, r/o fb, toxin ingestion, stomach ulcer, neoplasia. Returned today with copious amount of hematemesis – digested blood. Severely lethargic. Abdomen distended and painful.
- CBC and chem prof were wnl in the morning. PT/PTT was also wnl.
- 7 yr MI Lab Ret presented for inappetance and vomiting on 7/16/2020. Diagnosed w/ pancreatitis, r/o fb, toxin ingestion, stomach ulcer, neoplasia. Returned today with copious amount of hematemesis – digested blood. Severely lethargic. Abdomen distended and painful.
- CBC and chem prof were wnl in the morning. PT/PTT was also wnl.
- Abdominal US shows multiple (sublumbar, periportal, splenic, gastric, mesenteric) hypoechoic, enlarged lymph nodes (4.5cm) with adjacent echogenic fat. There is a thrombus at the splenic hilus and also possible thrombus at the portal hilus (PV). No ascites seen. Spleen is mildly enlarged and slightly mottled but shows parenchymal perfusion with CF Doppler. The stomach is empty with a thickened wall (1.5cm) and loss of wall detail. Echogenic fat is present adjacent to the stomach.
- The patient is moribund and passed a copious amount of melena at the end of the exam. US guided FNA was performed on the lymph nodes.
- My differential diagnoses for the intra-abdominal lymphadenopathy include neoplasia (lymphoma), mycobacterial infection, fungal. Differential diagnoses for the severe hemoptysis and melena include HGE, neoplasia, gastrointestinal ulceration, toxin, coagulopathy/DIC.
- What would your primary differential diagnoses be?
Comments
Those are hot and distorted
Those are hot and distorted LNs and thick stomach starting to lose layering. LSA or carcinoma with LN mets are my primary concern which is a commmon issue (LSA) causing hypercoagulable states and splenic thrombosis. I would do a full coag panel and fna the LNs and culture them just in case its a spetic set of LNs acting neoplastic. Pancreas is a bystander here with a front row seat.