Situs ambiguous with polysplenia with azygos continuation of the inferior vena cava (IVC) represents an exceptionally rare spectrum of congenital anomalies resulting from the disrupted left-right access development during embryogenesis. Although most reported cases are identified in childhood due to the associated cardiac and biliary malformations, survival into adulthood without major comorbidities is uncommon and rarely documented. We presented the case of a 37-year-old female who presented to the emergency department with left leg swelling and persistent nausea and vomiting. Imaging performed for unrelated symptoms revealed multiple right-sided spleens, a predominantly left-sided liver, and an infrahepatic IVC draining via the azygos system into the superior vena cava (SVC), all of which are findings consistent with sinus ambiguous with polysplenia. This case is unique in demonstrating the incidental asymptomatic presentation of this complex anomaly in an adult without significant cardiobiliary comorbidities. From a radiological standpoint, awareness of this pattern is critical to prevent misinterpretations as simply a vascular obstruction or post-operative change. Clinically, the recognition of this anomaly is essential for surgical planning, central venous access, and interpretation of cross-sectional imaging. Reporting exceptionally rare adult cases like this patient aids in expanding the understanding of this heterotaxy's variable spectrum and emphasizes the importance of accurate radiological identification in optimizing patient care.

Extrapulmonary tuberculosis is a common manifestation of tuberculosis, with lymph node involvement being the most frequent form. Among its presentations, periportal lymph node involvement leading to obstructive jaundice is extremely uncommon. Jaundice developing during anti-tubercular therapy (ATT) is frequently ascribed to drug-induced hepatotoxicity, which may contribute to delays in accurate diagnosis. We report a 17-year-old male with multidrug-resistant (MDR) lymph node tuberculosis who presented with progressive jaundice and right upper quadrant abdominal pain. Laboratory evaluation showed marked conjugated hyperbilirubinemia and cholestatic enzyme elevation. Ultrasonography, contrast-enhanced computed tomography (CECT), and magnetic resonance cholangiopancreatography (MRCP) revealed a large periportal and peripancreatic coalescent lymph nodal mass compressing the common bile duct (CBD), causing upstream biliary dilatation. Differential diagnoses included drug-induced hepatitis and cholangiocarcinoma, but radiology favored tuberculous lymphadenitis. The patient underwent percutaneous transhepatic biliary drainage (PTBD), with significant clinical improvement. He was subsequently restarted on the all-oral longer MDR regimen under careful monitoring. Obstructive jaundice due to tuberculous lymphadenopathy is a rare but important entity that may mimic drug-induced hepatitis or malignancy. Early imaging, biliary decompression, and individualized ATT modification are crucial. This case also highlights the rise and fall pattern associated with evolving drug resistance.

Pancreatic ductal adenocarcinoma (PDAC) is notorious for its aggressive tumour biology as well as its generally poor prognosis despite advances in systemic treatment. Oncological surgery with curative intent remains the hope for a potential cure for patients with pancreatic cancer. Apart from the usual tumour classification based on primary tumour, regional lymph nodal, and distant metastasis (TNM) staging, pancreatic cancer is also categorised into resectable, borderline resectable and locally advanced based on the anatomical relationship of the tumour with the adjacent important vasculature, namely superior mesenteric artery (SMA) and superior mesenteric vein (SMV), celiac trunk, common hepatic artery (CHA), portal vein (PV) to decide on resectability. The anatomical location of the pancreatic tumour and its extent decide the option of surgery, usually pancreaticoduodenectomy for head and uncinate tumours, whereas distal pancreatectomy for tumours in the body or tail. Sometimes, total pancreatectomy is indicated for extensive infiltrative tumours or multifocal tumours to achieve a negative resection margin. Variations in surgical techniques have been described to reduce the complications, e.g., postoperative pancreatic fistula (POPF), and the related morbidity or even mortality. However, no single technique has been shown to be consistently superior to the others in the literature. To further improve the resection margin clearance, extended resection techniques, namely radical antegrade modular pancreatosplenectomy (RAMPS), distal pancreatectomy with celiac axis resection (DP-CAR) (also known as modified Appleby procedure), were also described, but the benefit on overall survival is yet to be proven. For patients with unresectable or locally advanced pancreatic tumour, sometimes surgical bypass with palliative intent could be performed to relieve the biliary or duodenal obstruction. There is a potential role of tumour ablative therapy, either by thermal energy or non-thermal [e.g., irreversible electroporation (IRE), radiofrequency ablation, or microwave ablation], for local tumour control; however, evidence is still limited to conclude its value. Management of PDAC is often challenging for the surgeon and very often necessitates a multidisciplinary meeting for conjoint decision and collaboration for subsequent tailored management.

Ascariasis is a widespread helminthic infection, yet the long-term hepatic consequences of larval migration remain poorly understood. Evidence indicates that tissue damage may persist beyond parasite clearance. While chronic cholestatic liver disease is classically associated with obstructive, autoimmune, or genetic disorders, parasitic infections such as ascariasis may represent an overlooked etiology. This study investigated post-migratory hepatic effects of Ascaris suum larvae in a mouse model, evaluating dose-dependent and exposure-frequency paradigms. Female BALB/c mice were infected with A. suum eggs using low-dose (250 eggs) or high-dose (2500 eggs), administered as single or reinfection (14 days apart). Mice were euthanized at three time points, day 4 post-infection (dpi) (peak hepatic migration phase), or 35 and 100 dpi (post-hepatic clearance). Livers were analyzed for parasite burden (4 dpi), cytokine gene expression, and comprehensive histopathological analysis (35/100 dpi). Plasma was assessed for biochemical markers (AST, ALT, GGT, ALP, total bilirubin and fractions, and albumin) and cytokine quantification. Histological analysis revealed persistent hepatic inflammation and fibrotic remodeling up to 100 dpi. Biochemical assays confirmed cholestatic dysfunction with elevated ALP, GGT, and bilirubin. Gene expression analysis showed sustained inflammatory signaling. These findings establish that larval migration induces chronic hepatobiliary injury and cholestasis, independent of peak burden. Importantly, pathology occurred without adult worm-mediated biliary obstruction, identifying a novel helminth-driven hepatic disease mechanism. Our findings demonstrated that ascariasis, even at low infection intensities and in the absence of adult worm establishment, can induce persistent hepatic inflammation, fibrotic progression, and cholestatic dysfunction. This evidence challenges the prevailing paradigm that biliary obstruction by adult worms is the exclusive mechanism of hepatobiliary injury in ascariasis. Our results underscore the significant pathogenic potential of larval stages and their ability to provoke chronic liver pathology that persists well beyond parasite clearance. These observations are clinically relevant for endemic regions, where recurrent low-level exposure may lead to cumulative liver damage despite the absence of overt adult worm infection.

Esophageal adenocarcinoma (EAC) is an aggressive malignancy with a poor prognosis, especially in advanced stages. Common metastatic sites include the liver, lungs, adrenal glands, lymph nodes, and bones; however, metastasis to the biliary tree is exceedingly rare. We report the case of a 50-year-old male with a history of testicular cancer in remission and metastatic EAC involving the liver, lungs, adrenal glands, peritoneum, bones, and lymph nodes. The patient presented with acute onset jaundice but no abdominal pain, fever, or gastrointestinal symptoms. Laboratory findings revealed significant cholestasis, and imaging demonstrated biliary tree dilation with obstruction at the distal common bile duct. ERCP was unsuccessful due to duodenal invasion by the tumor, which precluded access to the biliary system. Endoscopic ultrasound-guided biliary drainage was performed, and a stent was successfully placed. The patient subsequently developed post-ERCP pancreatitis, which was managed conservatively with intravenous fluids. This case illustrates a highly uncommon metastatic pattern of EAC, with involvement of both the biliary tree and the duodenum, leading to obstructive jaundice and necessitating advanced endoscopic intervention. The combination of widespread metastasis, duodenal obstruction, and biliary involvement makes this presentation exceptionally rare. It also underscores the importance of recognizing atypical manifestations of metastatic EAC and highlights the critical role of endoscopic ultrasound in managing complex biliary obstructions when standard approaches fail. To our knowledge, very few cases of EAC metastasizing to the biliary tree have been reported, making this case a valuable addition to the medical literature and clinical understanding of EAC.