The term bezoar refers to a foreign object found like a mass of concretion in the gastrointestinal tract that results from an accumulation of undigested material. When the composition of the ingested material is a medication, it is known as a pharmacobezoar. A rare complication from pharmacobezoar is large intestinal obstruction. Here we present the case of a 77-year-old male who presented with progressive abdominal distension, involuntary guarding, and large bowel obstruction. Abdominal imaging studies were remarkable for radiopaque objects of uncertain etiology in the transverse colon and rectal ampulla. The patient underwent colonic decompression by sigmoidoscopy, where the pills were identified by direct visualization. He later underwent endoscopic removal of the pharmacobezoars. A detailed medication review identified the culprit to be multivitamins. This case portrays an unusual etiology of large bowel obstruction. At this moment, no cases have been reported of multivitamins as the culprit of pharmacobezoar with subsequent development of large bowel obstruction. The term bezoar refers to a foreign object clumped as a mass in the gastrointestinal tract resulting from the accumulation of undigested material. It is referred to as a pharmacobezoar when the composition of the ingested material is a medication -2. Some A 77-year-old male with a medical history of hypertension, diabetes mellitus type II, chronic constipation, benign prostatic hyperplasia with chronic indwelling foley, hypothyroidism, and advanced dementia with behavioral disturbances. The patient's home medication list included buspirone, levothyroxine, terazosin, and multivitamins. He was brought to the emergency department (ED) by his caretaker after he presented with general malaise, shortness of breath, and foul-smelling urine. Associated symptoms included two episodes of emesis, described as dark content. Vital signs were pertinent for a fever of 100.4°F and tachycardia of 136 bpm. Physical examination showed a distended abdominal wall but without tenderness or symptoms of peritoneal irritation. Laboratory workup revealed neutrophilic leukocytosis of 13.8x109/uL and normal hemoglobin level. The comprehensive metabolic panel was consistent with acute kidney injury stage I with a creatinine increase from 0.9 mg/dL to 1.4 mg/dL  and elevated lactic acid in 3.1 mmol/L . Urinalysis showed pyuria and bacteriuria.Due to abdominal distention, a plain radiograph was ordered, which showed a non-obstructive bowel gas pattern, air distention of the sigmoid colon, and the presence of multiple retained radio-opaque foreign bodies in the rectal ampulla and at the right upper quadrant of uncertain etiology Figure . He was Admission was complicated with worsening abdominal distention and obstipation. Despite following gastroenterology service recommendations, a follow-up abdominal X-ray showed progression of air distention in the sigmoid colon, fecal impaction, and redemonstration of multiple radio-opaque densities within the rectum Figure . On day The team performed a colonoscopic decompression for which a rectal tube was placed. At this moment, the pharmacobezoars were not removed because of the increased risk of intestinal perforation secondary to colonic distention. The follow-up X-ray showed a decrease in the amount of bowel gas and an improvement in large bowel distention. Additional findings included retained feces and an unchanged amount of the radio-opaque foreign bodies. After the procedure, the surgical team recommended serial enemas every 8 hours to manage fecal impaction, but the patient was uncooperative with treatment. Following decompression, the patient had no bowel movements, nor was he passing flatus. Physical examination demonstrated persistent abdominal pain and distention. On day 8 of admission, after addressing colonic distention, the surgery team was able to take the patient to the OR for colonoscopic removal of the pharmacobezoar to relieve the intestinal obstruction. Over 35 pills were removed successfully Figure , and a fA detailed revision of his medication list was done, and the only drug found to have the same characteristics as the pills removed by colonoscopy were the multivitamins. From the medications listed, it is the only drug with a radiodense appearance on a plain radiograph. This characteristic is secondary to the ingredient potassium chloride found in the vitamins the patient was taking, a trait not shared by any other outpatient medication. It also shared the same morphology and size as the ones removed through colonoscopy, which further supported that the multivitamin was the culprit. Upon discharge to his nursing home, instructions were to continue stool softeners and laxative agents as treatment for constipation but discontinue the use of multivitamins, as these were potentially the cause for the pharmacobezoar. Pharmacobezoars are a rare cause of colonic obstruction and can be seen with medications such as fiber-containing laxatives, enteric-coated tablets, and extended-release drugs . Some caAn accurate diagnosis can be challenging and relies on the bezoar's location. Initial evaluation frequently involves plain radiography or CT scan, which can aid in identifying radiopaque drugs . Sieron When a pharmacobezoar is encountered, a detailed medication reconciliation needs to be performed and the culprit discontinued to avoid the recurrence of intestinal obstruction. This should always include non-prescribed, over-the-counter medications or vitamin supplements that the patient can be taking. Treatment will depend on the bezoar's location, size, and nature. The mainstay for treating uncomplicated intestinal obstruction is conservative management with laxative agents, enemas, manual disimpaction, and close monitoring with serial abdominal imaging. If conservative management fails, a more invasive approach with colonoscopy, endoscopy, or surgery must be taken . In the Even though pharmacobezoar is a rare entity of large bowel obstruction, it is important to keep it in our differential. This will lead the therapeutic plan and approach. Additionally, it is vital to recognize patients with comorbidities and anatomical variations that pose an increased risk for the development of this complication because even if it is infrequent, intestinal obstruction could result in a fatal outcome. Diagnosis can be suggested by different imaging modalities, which include a plain radiograph, CT scan, or ultrasound, but confirmation of the diagnosis is done by direct visualization of the bezoar. The therapeutic approach will be dictated by the bezoar's location, size, and nature. This case highlights a rare etiology of bowel obstruction, the importance of prompt diagnosis, the role of medication reconciliation, and colonoscopy as the removal technique.


Meningioma treatments, including complete surgical resection, debulking, radiation therapy, and palliative care in dogs and cats have recently been improved. Although complete resection of meningiomas is known to be the most effective treatment, there are still challenges in performing safe surgeries due to the presence of numerous vessels surrounding the tumor and brain parenchyma. Many efforts have been made in the field of human medicine to achieve safety, such as preoperative planning using 3D simulation and contrast angiography. Surgical navigation systems have been studied for application, but recently, three-dimensional techniques have helped surgeons perioperatively. This study enhanced the vessels around the meningiomas in the skull and attempted to identify them using 3D computed tomography and magnetic resonance imaging angiography rather than conventional angiography. An 11-year-old castrated male cat was referred to our hospital with a meningioma located in the occipital lobe. The cat showed progressive tetraparesis. Throughout the long-term follow-up, following the complete removal of the meningioma, the cat showed favorable clinical outcomes and no neurological abnormalities.We present a case of occipital lobe meningioma resection in an elderly cat. The surgery was performed with the goal of avoiding major bleeding. An 11-year-old castrated indoor-only male Persian Chinchilla (5.5 kg) was presented with a month-long history of progressive tetraparesis for a left occipital lobe meningioma. Magnetic resonance imaging revealed a T2-weighted heterogeneously hyperintensity and a T1-weighted well-contrast enhancing extradural mass in the left occipital lobe of the brain. Cerebral angiographic data were obtained using magnetic resonance (MRA) and computed tomography angiography (CTA). Advanced angiograms and virtual reconstruction of images revealed that the tumor was surrounded by the caudal parasagittal meningeal vein. A left caudal rostrotentorial craniotomy and en bloc resection of the tumor were performed, and histopathology revealed a meningioma. Complete neurological recovery was achieved within 10 days after surgery. To the best of our knowledge, this is the first case report describing CTA and MRA findings and favorable clinical outcomes after surgical management of a brain meningioma without severe perioperative complications. Feline intracranial meningiomas are mainly benign extra-axial brain tumors that grow from the meninges and can be attached to the dura mater; they have been reported to occur frequently in primary intracranial neoplasia . IntracrThere are various treatment options, such as chemotherapy and radiotherapy, although surgical resection is reported to be the most effective ,3,4. SinDiverse advances, such as minimally invasive techniques, approaches, and surgical devices, have been developed to overcome the challenges of brain surgery . FurtherHowever, to the best of our knowledge, there are no published reports on the use of advanced imaging angiograms for surgical planning of occipital lobe meningiomas in cats. This case report describes the application of CTA, MRA, and 3D printing techniques in the surgical planning of intracranial meningiomas in elderly cats, primarily to avoid injury to major brain vessels for better surgical outcomes.An 11-year-old castrated indoor-only male Persian Chinchilla (5.5 kg) was referred to our hospital for left occipital lobe meningioma. The patient had a history of progressive tetraparesis that lasted for six months prior to the presentation. Two weeks prior to the presentation, the patient showed altered mental status due to anorexia and was admitted to a local hospital. The patient had a tonic-clonic seizure for 15 s during hospitalization, and no seizures were observed after discharge. The primary veterinarian had prescribed anticonvulsants because of the seizure, including gabapentin (10 mg/kg PO twice daily), phenobarbital (3 mg/kg PO twice daily), and levetiracetam (15 mg/kg PO twice daily). The day after discharge, the patient was referred to a local veterinary imaging center and admitted for magnetic resonance imaging (MRI). The patient was referred to our hospital with a suspected left occipital lobe meningioma. On presentation, the abnormal physical findings included ataxia and lethargy. Abnormalities observed duirng the neurological examination included obtundation and symmetrical cerebellar pelvic limb ataxia. However, the other neurological findings were normal. The patient was assessed with a score of 16/18 according to the Modified Glasgow Coma Scale, which falls into the Score III category with a good prognosis . There wGeneral anesthesia was induced with propofol (4 mg/kg IV) and maintained with inhaled isoflurane and oxygen. The MRI sequences included 3-plane scout localizers, T1-weighted , T2-weighted , FLAIR (TR/TE = 8000/77 on transverse plane), and postcontrast T1-weighted  images with a slice thickness of 2 mm. The MRI revealed a round, solitary, well-defined mass with a homogenous hypointensity when compared to gray matter in T1-weighted images, dura tail signs in T1-weighted contrast images, and edematous changes around the occipital lobe tumor in T2-weighted images. There was no sign of hyperostosis in the bone surrounding the mass .®+ Injector System, Bracco, Italy) was attached to the patient via a 24-gauge intravenous catheter in the cephalic vein. First, a precontrast scan was performed to define the location of the carotid artery for bolus tracking. After defining the location of the common carotid artery, a 2.5 mL/kg dose of iodinated contrast medium (600 mg iohexol/kg) was injected at a 1.5 mL/s injection rate. Hounsfield unit of the common carotid artery was monitored, and scans were manually initiated immediately after opacification of the artery to obtain an arteriogram. A venogram scan was started 30 s after the arteriography. On CTA, the transverse sinus was intact  (0.1 mmol Meglumine gadoterate/kg). Signals from the cerebral arteries were not identified on the MRA. Additionally, no evidence of neoplastic invasion of surrounding vessels was observed. The cerebral arteries and veins were manually segmented using the original and post-processed datasets. The virtual reconstruction of the brain was performed using an image-processing program   and magnetic resonance angiography (MRA) after the MRI scan . After ts intact A, yet ths intact B. In addGermany)  27]..®+ Injecwww.slicer.org] accessed on 24 November 2021). With the MR images and virtual images of MRA, rehearsal surgery was performed using 3D modeling software  to determine the operation window in order to minimize surgical damage to the skull and surrounding tissues. In addition, a virtual 3D surgical guide was designed using 3D modeling software  to cover the bony surface of the window for the exact location during the operation , anesthetized with propofol (4 mg/kg IV), and maintained with isoflurane. Intraoperative analgesia was provided by a constant rate infusion (CRI) of remifentanil (0.1–0.3 μg/kg/min). The patient was positioned sternally and recumbently, and the head was slightly tilted so that the meningioma was positioned at the highest point . All the®, Ethicon, Somerville, NJ, USA), gelatin sponge , and Floseal  were used to manage bleeding . Hemostatic products, such as regenerated cellulose  to prevent excitement. All vital signs were normal and the appetite came back on postoperative day two. On postoperative day nine, gait improved, yet mild ataxia in the right hindlimb was still present. No other neurological deficits were clinically observed. Ten days after the surgery, the patient was discharged.Histopathological examination revealed a grade 1 intracranial mass, a psammomatous subtype, and a meningioma . The resWe present a case of occipital lobe meningioma resection with the goal of avoiding major bleeding in an elderly cat. To minimize hemorrhage during surgery, preoperative CTA, MRA, and virtual 3D rehearsals were performed, and a 3D printing surgical guide was used. Therefore, the surgery was successfully performed without significant blood loss, and the patient completely recovered from the surgery despite its concerning older age.Surgery involving the occipital lobes may have significant postoperative risks, ranging from neurological deficits to surgery-related deaths ,33,34,35In human medicine, various efforts to mitigate blood loss during resection, including accurate assessment of the vasculature and preoperative embolization, are utilized for patients with intracranial tumors ,22,42. TPreoperative images could provide information regarding the meningioma and its neighboring vasculature in detail. Thus, the surgical techniques applied in this case were mainly focused on minimizing iatrogenic damage to the surrounding blood vessels, such as the parasagittal sinus. Several advanced techniques, that were extrapolated from human medical procedures, have been applied in this case ,39,44,45This study had several limitations. First, this single case does not represent all elderly feline patients with occipital meningiomas. Further studies should be performed to characterize feline occipital meningiomas, particularly in geriatric populations. Moreover, due to the small size of the patient, arterial angiography could not be performed. Thus, the feeding arteries of the meningioma may have been overlooked in this case. Additionally, we did not perform a follow-up CT or MRI postoperatively to assess nerve tissue adaptation and local adaptive or pathological changes. Simple clinical evaluation does not fully represent the extent of tumor removal, as well as changes that occur in surrounding tissue following surgery. Lastly, the deleterious effects of applied angiograms have been reported at low rates in human medicine . AlthougIn this study, by using advanced angiography techniques, such as CTA and MRA, we defined the displacement of peritumoral vessels in the preoperative plan. Although these angiographies are not routinely used in veterinary medicine, understanding the intracranial vasculature is essential for better surgical outcomes, especially in elderly patients prone to complications related to blood loss during surgery. To make surgical resection a feasible choice with a guaranteed acceptable outcome in elderly patients, an appropriate assessment of intracranial vascularity should be considered.


Appendiceal inversion is uncommon. It may be a benign finding or seen in association with malignant pathology. When detected, it masquerades as a cecal polyp which poses a diagnostic dilemma with malignancy in the differential. In this report, we highlight a case of a 51-year-old patient with an extensive surgical history as a newborn in the setting of omphalocele and intestinal malrotation, who was found to have a 4 cm cecal polypoid growth on screening colonoscopy. He underwent a cecectomy for tissue diagnosis. Ultimately, the polyp was found to be an inverted appendix without evidence of malignancy. Currently, suspicious colorectal lesions which cannot be removed by polypectomy are primarily addressed with surgical excision. We reviewed the literature for available diagnostic adjuncts to better differentiate benign from malignant colorectal pathology. The application of advanced imaging and molecular technology will allow for improved diagnostic accuracy and subsequent operative planning. Appendiceal inversion is uncommon, seen in up to 1.5% of colonoscopies, and presents a diagnostic challenge . AppendiSeveral factors could help differentiate benign from malignant cecal polyps. Ileocecal thickening greater than 3 mm is considered abnormal and characteristic of the inflammatory or neoplastic process . CalcifiThis report describes the case of a 51-year-old male patient with a history of omphalocele and intestinal malrotation, requiring multiple abdominal surgeries including appendectomy, as a newborn. He was found to have a cecal mass on screening colonoscopy. This finding was followed by CT demonstrating a 4.5 cm peripherally calcified tubular structure within the lumen of the cecum with associated cecal wall thickening  screening include colonoscopy, computed tomographic colonography (CTC), as well as stool-based tests including fecal immunochemical and multitarget DNA tests. While colonoscopy remains the gold standard for CRC screening, newer detection modalities with advanced imaging, endoscopy, molecular technology and artificial intelligence (AI) / machine learning (ML) may improve diagnostic accuracy.The technique most comparable to colonoscopy in detecting advanced colorectal neoplasia, with a sensitivity of 96.1%, is CTC . ComputeAdvanced endoscopy applications also show significant promise in differentiating benign from malignant polyps. Techniques such as non-selective fluorophore indocyanine green (ICG) with near-infrared (NIR) technology allow for enhanced real-time assessment of tissue microperfusion. Malignant lesions demonstrate dynamic curves which peak significantly later compared to benign lesions, which demonstrate a faster intensity drop . AdditioAn emerging area of research involves AI-assisted colonoscopy for colorectal polyp detection and characterization. This utilizes computer-aided detection (CAD), an artificial neural network and deep learning technique that is highly effective at performing medical image analysis. Multiple CADs have been developed and are being studied for colorectal polyp detection and characterization. For instance, improved adenoma detection rate within small polyps using CAD during real-time colonoscopy has been previously demonstrated . ArtificTo this day, colonoscopy remains the gold standard modality for CRC screening with biopsy and polypectomy performed for diagnosis. Albeit rare, an inverted appendix can masquerade as a cecal polyp at the appendiceal orifice and may harbor appendiceal mucinous neoplasms, neuroendocrine tumors, and other malignancies. Currently, suspicious colorectal lesions which cannot be removed by polypectomy due to large size or risk of bowel perforation, such as the one seen in our patient, are primarily addressed with surgical excision. This approach is invasive and carries the risk of bleeding, infection, damage to nearby structures, and more. The reviewed diagnostic adjuncts which include advanced imaging, endoscopy, molecular technology, and AI/ML may improve diagnostic accuracy to better differentiate benign from malignant colorectal pathology. Application of such adjuncts in the future will help further categorize suspicious colorectal lesions that would otherwise require polypectomy or surgical excision. This paves the way for less invasive methods of CRC screening and selecting those patients who would further benefit from surgery.


A 9-year-old, spayed female, mixed-breed dog was initially presented for evaluation of chronic dermatitis on the nasal planum, where a clitoral mass was discovered as an incidental finding during the exam. No further investigation of the clitoral mass was undertaken due to other significant dermal lesions and the lack of clinical significance of the mass at the time. However, ~1 month later, the dog was presented to the Emergency Service for bleeding from the vulva. The clitoral mass was found to have prolapsed; the mass was manually reduced back into a position within the vulvar folds and maintained with a purse-string suture. The dog was referred to the Theriogenology Service for further investigation and removal. On follow-up evaluation, the mass was noted to be multi-lobulated, ulcerated, cystic, and involving the clitoris but not the urethra. The urethra was easily catheterized, and no urinary abnormalities were found. No evidence of lymph node metastasis or hypercalcemia was noted prior to surgery. Ultrasonographic evaluation of the anal sacs was normal. The mass was removed, and histopathologic evaluation revealed a primary clitoral adenocarcinoma. On recheck evaluation, after 1 month, no evidence of metastasis or local recurrence was observed. Clitoral adenocarcinoma is a rarely reported neoplasm of the canine genital tract that shares many clinical, histopathological, and immunohistochemical features with canine apocrine gland anal sac adenocarcinoma. This case adds to the available knowledge on the condition, specifically regarding the frequency of complications such as hypercalcemia and metastasis, as previous reports suggest that these are present at least 50% of the time. Vaginal and vulvar tumors are uncommon neoplasms in the bitch, representing 3% of all canine neoplasms . SpecifiA 9-year-old, spayed female, mixed-breed canine presented to the Veterinary Teaching Hospital Community Practice Service at the Virginia-Maryland College of Veterinary Medicine for evaluation of a nose lesion present for 6 months. The dog was initially treated with cephalexin for 14 days, which resolved a secondary bacterial component but did not eradicate the underlying primary skin lesion. The lesion was reported by the owner to have a cyclic appearance, sometimes presenting as inflamed and ulcerated and at other times seeming to regress. No underlying cause had yet been determined. On examination of the dog, vital parameters were within normal limits. Several cutaneous masses on the forelimbs and a vulvar mass  were alsThe dog was presented 1 month later to the VTH Emergency Service for evaluation of a bleeding vulvar mass. The owner reported that consistent, mild hemorrhage had been noted from the vulva after the dog had played outside for a period of a few hours. The dog was reported to have recently developed an increased frequency of vulvar licking. On presentation to the Emergency Service, vital parameters were within normal limits, and no peripheral lymphadenomegaly was detected. A large, ulcerated mass was noted protruding from the vulva; the mass was noted to seem larger than it had 1 month before. The perineal area was clipped and aseptically prepared, and then the mass was manually reduced back into the vulva. A purse-string suture was placed to contain the mass within the vulva. Evaluation by the Theriogenology Service was recommended within the next 48–72 h to discuss additional diagnostics and mass removal. No additional medications were prescribed at this appointment.via ultrasonography) was noted on the ventral wall of the vestibule below the clitoris , leading to a similar lineage of cells in the clitoris as in the anal sacs and thus the ability to develop adenocarcinoma of the clitoris . The norThough it was not observed in our case, hypercalcemia has been associated with 50% of the previously reported cases of clitoral adenocarcinoma and, in some cases, may have been the complication leading to the decision for euthanasia , 2, 6, 8Local lymph node metastasis was confirmed histologically in 60% of the previous case reports of canine clitoral adenocarcinoma. Reported sites of lymph node metastasis include the inguinal lymph nodes, the iliac lymph nodes, and the hypogastric lymph nodes , 2, 7, 8The histological description of the clitoral adenocarcinoma removed from our case is similar to what has been described in previous cases. These tumors are generally multi-lobulated or nodular and moderately to well demarcated. They can be unencapsulated, partially encapsulated, or fully encapsulated. They often efface the normal architecture of the clitoris , 2, 6–8.Surgical treatment was pursued in 70% of the previous cases of clitoral adenocarcinoma, with or without adjunctive chemotherapy. Three of the seven dogs undergoing surgery were later euthanized, with the other four either being reported as still alive or having no report of death. Dogs that underwent surgical excision for canine apocrine gland anal sac adenocarcinomas had longer median survival times than those not undergoing surgery as part of their treatment . SimilarMetastasis at presentation has been reported in both survivors and non-survivors of canine clitoral adenocarcinoma . It has Canine clitoral adenocarcinoma is a rarely reported condition with outcomes ranging from no evidence of recurrence or metastasis, as observed in this case, to euthanasia secondary to tumor-related issues. Additional case reports are needed to better characterize the prognosis and incidence of complications associated with this condition so that owners may be well informed when considering treatment options. This case report contributes to the advancement of our knowledge concerning this rare canine neoplasm.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The animal studies were approved by Virginia-Maryland College of Veterinary Medicine. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent was obtained from the owners for the participation of their animals in this study.CM: Writing—original draft. NS: Writing—review and editing. RP: Writing—review and editing. BC: Writing—review and editing. KL: Writing—review and editing. JC: Supervision, Writing—review and editing.


This is the first reported case of a pelvic gunshot wound with a bladder injury masking a coinciding left external iliac artery injury. A high index of suspicion for an acute and traumatic ilio‐vesical fistula should be raised in the presence of the following triad: bright red hematuria, bladder distension from clot retention, hemodynamic instability after bladder decompression “Mukendi's triad.”Iliac artery injury from gunshot wounds is very rare and a lethal injury associated with high mortality rate. Concurrent ballistic external iliac artery and bladder injuries resulting in an acute ilio‐vesical shunt or fistula and discovered at the time of presentation are extremely rare.In this report, we present an unprecedented case of multiple pelvic gunshot wounds presented with a distended injured bladder full of clots concealing a left external iliac injury by tamponade effect. We noted a through and through gunshot wound of the left hemi‐scrotum; two wounds on the left upper thigh; one on the left groin and another one on the right lower back. He had normal lower limb pulses. The focused assessment with sonography for trauma exam was negative for free fluid but showed a distended bladder. The results of hemoglobin, serum urea, electrolytes, and creatinine were within normal limits. A CT abdopelvis and angiography was done and showed bladder clot and no vascular injury. The patient was taken to the theater for an emergency scrotal exploration and cystoscopy. Scrotal exploration and left orchidectomy for shattered testis were performed followed by cystoscopy. The cystoscopy was difficult and short due to poor vision by bright red bleeding and sudden hemodynamic instability after decompressing the bladder. The procedure was immediately abandoned, and an exploratory laparotomy promptly commenced. Emergency blood was ordered, and cell saver plugged in and connected for immediate use. On entering the abdomen, there was no obvious bleeding and the patient was more stable. The bladder was noted to be distended and erythematous. A longitudinal incision was made on the anterior wall of the bladder Figure  extended3Traumatic arteriovesical fistula and specifically between the external iliac artery and the bladder is rare.Other common causes of this entity include previous pelvic surgery and iatrogenic injury, radiotherapy, and vascular disease.The rarity of this condition is evidenced by the paucity of literature related to it. However, in cases of recurrent and/or persistent unexplained hematuria following trauma, bladder or pelvic surgery, radiotherapy, or pelvic vascular disease, angiography can be performed to define the site, size, and extent of the fistula.Interestingly, we noted three signs which were linked to this acute arteriovesical fistula, including bright red hematuria, clot retention or distended bladder, and hemodynamic instability upon disobstruction or catheterization. In a setting of penetrating pelvic trauma, urologists and/or trauma surgeons should have a high index of suspicion for an acute and traumatic arteriovesical fistula in the presence of this triad.Once the diagnosis is made, a therapeutic plan should promptly be put in place. There is no agreement or guidelines in the literature with regard to managing this entity. However, in the emergency setting and when the patient is unstable, an open surgical approach and repair of the defects is the more likely option as there is a need to evaluate for other injuries.4External iliac artery injuries are rare and should be promptly recognized and urgently managed to reduce the already known high mortality rate. Acute traumatic ilio‐vesical fistula is very uncommon, and this report was the first to describe a case of bladder injury concealing a concurrent external iliac artery injury.In a setting of penetrating pelvic trauma, urologists and/or trauma surgeons should have a high index of suspicion for an acute and traumatic arteriovesical fistula or shunt in the presence of the following triad: bright red hematuria, clot retention or palpable bladder, hemodynamic instability after bladder decompression “Mukendi's triad”.Alain Mwamba Mukendi: Conceptualization; data curation; resources; writing – original draft; writing – review and editing. Charles Eustachia Mathye: Writing – original draft.None.The authors declare no conflicts of interest.The study was approved by the University of the Witwatersrand Human Research Ethics Committee . All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Patient informed consent was obtained for publication and is available on request.Written informed consent was obtained from the Head of Department Dr. Mathye for publication of this manuscript and accompanying pictures as the patient was unconscious until demised and we could not trace any family member. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal.


T‐cell lymphoma in the gastrointestinal tract  is rare. ITCL, not otherwise specified  which is a type of ITCL is particularly rare. There are few case reports of ITCL, NOS but no previous reports describe its endoscopic features. In this report, the 69‐year‐old man was diagnosed with ITCL, NOS. Colonoscopy revealed the elevated legion and edematous mucosa with focal depressions in the lower rectum. On the depressed legions, magnifying endoscopy combined with narrow‐band imaging detected the disappearance of glandular structure and branching abnormal blood vessels like a tree. These findings were similar to the tree‐like appearance, which has been described as a unique feature of gastric mucosal‐associated lymphoid tissue lymphoma. The targeted biopsy of the tree‐like appearance showed abnormal histopathological findings which fit the definition of ITCL, NOS. He was treated with chemotherapy and achieved complete remission. As is the case of gastric mucosal‐associated lymphoid tissue lymphoma, the tree‐like appearance is possibly the unique sign of ITCL, NOS. We report the endoscopic features of ITCL, NOS and show characteristic findings by magnifying endoscopy combined with narrow‐band imaging. Primary gastrointestinal (GI) lymphomas account for 1–8% of GI malignancies.The patient was a 69‐year‐old man who underwent periodical follow‐up colonoscopies every year because of colon polyps. Colonoscopy revealed no abnormalities in the previous year. He had a history of pharyngeal and esophageal cancers, which had achieved a complete response to chemoradiation therapy 13 years ago. A colonoscopy was performed as usual without any complaint and revealed an elevated lesion with a diameter of 20 mm in the lower rectum Figure . The lesITCL is very rare, accounting for less than 5% of primary GI lymphomas.ME combined with NBI demonstrated the TLA  on the depressed legions in the lower rectum. This has been described as a unique feature that is suggestive of gastric mucosal‐associated lymphoid tissue lymphoma.The present case was diagnosed by re‐examination of colonoscopy and histopathology. A correct diagnosis was made based on the examination of the biopsy specimens obtained from the site of the TLA, which had been detected by ME combined with NBI. Similar to a previous report related to gastric mucosal‐associated lymphoid tissue lymphoma, targeted biopsy of the TLA was useful in the diagnosis of lymphoproliferative diseases, including the present case.This report is the first to describe the endoscopic features of ITCL, NOS, and the relationship between the TLA and ITCL, NOS. This case suggests new information on the specific endoscopic features of ITCL, NOS and could contribute to the endoscopic diagnosis. Although our report is limited to a single case, the TLA could be a unique endoscopic feature that is suggestive of ITCL, NOS.None.Click here for additional data file.


Intestinal Malrotation is congenital that complicates 1 in every 200 births. It results from abnormal fixation and rotation of the gut tube during fetal development. It is usually asymptomatic and most cases are diagnosed during childhood and the condition is seldom seen in adults. Also, it can present as an incidental finding in imaging or patients undergoing laparotomy for other reasons. Midgut Volvulus can lead to small obstruction it warrants surgical intervention.Our case is a 20 years old black African male from Khartoum (Sudan) who presented to the emergency department with features of intestinal obstruction he was resuscitated and underwent a CT scan of the abdomen that showed malrotation of the intestine with volvulus for which he underwent a Ladd procedure.Small bowel obstruction due to volvulus complicating malrotation is a rare presentation in adulthood and the Ladd procedure can be utilized to manage such case. The intestine is made of foregut, midgut and hindgut. During the fourth week of embryonic development the midgut increases in length and the abdominal cavity can’t accommodate it and so it herniates through the umbilicus. During the tenth week of development, the midgut returns back to the abdomen and while doing so it rotates a 270° counter clockwise around the axis of the superior mesenteric artery, which supplies it so that the right colon is placed on the right side of the body. Failure of this process results in the formation of the midgut malrotation. The exact cause is not yet established, but there is often a fibrous band(ladd band) that tethers the right colon, preventing it from rotation and can lead to symptoms of obstruction .A 20-year-old black African male from Sudan presented to Omdurman teaching hospital Emergency department complaining of acute onset colicky abdominal pain the patient passed flatus and feces 48 h prior to his presentation. also had vomiting and abdominal distension. He had a clear medical background with no history of operation before. After the initial assessment positive findings were abdominal distension, hyper-resonance in percussion, and exacerbated bowel sound, all blood lab results were normal. Management was started at the emergency department with a nasogastric tube and urinary catheter insertion. Intravenous fluids, broad-spectrum antibiotics. Abdominal X-ray showed multiple air-fluid levels and dilated loops of the bowel. Chest X-ray did not show air under the diaphragm.An emergency computed tomography (CT) scan was obtained which demonstrated dilated caecum was located in the left upper quadrant and small-bowel volvulus Figs. , 2. TherThe findings of the operation included dilated small bowel in the upper abdomen and a dilated caecum found on the left side of the abdomen, DJ flexure on the right side Figs. , 4. TherThe patient had an uneventful postoperative recovery. He was followed up one month later in the outpatient department and he had no complaints and returned to his normal baseline.Abnormal bowel rotation during Embryogenesis leads to the development of Malrotation and there different classification for the condition based on the degree of the rotation. According to stinger classification, there are three types of malrotation. Type 1: non-rotation, type 2: duodenal malrotation and type 3: duodenal plus caecal malrotation. Also, there is malfixation of the mesentery with a narrow pedicle that can result in volvulus. Several conditions are associated with midgut malrotation like Martinez-Friay syndrome where malrotation is associated with multiple GI atresia [In pediatric patients, intestinal malrotation presents early with symptoms of small bowel obstruction  and can be diagnosed with upper GI contrast series. However, most adults with malrotation are often diagnosed accidentally during imaging or exploratory laparotomy for other causes . Many adBoth CT scans and upper GI series can help to detect malrotation. They can show the abnormal position of the caecum on the left and the abnormal relationship of the Superior mesenteric artery and superior mesenteric vein and SMV . Midgut volvulus is easier to be found in the upper GI series , but because most adults undergo a contrast CT scan you might find a whirlpool appearance (swirling appearance of bowel and mesentery twisted around the axis of the superior mesenteric artery). Other features are duodenal obstruction and mesenteric vasculature congestion .Children and adults who were found to have symptomatic malrotation should undergo surgery . ladd's Malrotation presenting with small bowel obstruction in adults is a rare presentation of the condition can be difficult to diagnosed clinically. Imaging is of great use to allow diagnoses and pre-operative planning. Ladd procedure can be carried out in the in adult as well but sometimes necrotic may need to be resected to complete the procedure.


Sarcoid-like granulomatous inflammation (SLGI) is defined as the development of non-necrotizing epithelioid granulomas in patients who do not meet the criteria for systemic sarcoidosis. Its occurrence is known to be linked to diverse conditions, including malignancies, infections, the use of certain drugs and inorganic substances. To the best of our knowledge, the available literature to date lacks any description regarding SLGI in a paraganglioma. The present study describes the first case of SLGI in a carotid body paraganglioma (CBP). A 54-year-old female patient presented with anterior neck swelling for 27 years without any other symptoms. An ultrasonography revealed a multinodular goiter with retrosternal extension and a solid lesion on the right side of the neck measuring 40x30x22 mm, which was suggestive of a CBP. The patient underwent a total thyroidectomy, and the right-side cervical mass was resected via another longitudinal incision. A histopathological examination of the thyroid specimen revealed findings of a multinodular goiter. Sections from the right-side cervical mass confirmed the diagnosis of CBP accompanied by multiple, well-formed, small-medium sized, non-necrotizing epithelioid granulomas associated with multinucleated giant cells, indicative of SLGI. Non-necrotizing epithelioid cell granulomas (as with SLGIs), identical to those observed in sarcoidosis, may rarely be observed in patients who do not meet the criteria of systemic sarcoidosis; however, they have been observed in association with various neoplasms. It is thus crucial to distinguish them from actual sarcoidosis, as misdiagnoses may lead to severe consequences. The presence of SLGIs accompanying a paraganglioma is an extremely rare phenomenon. Due to this, it is difficult to conclude if it confers a better prognosis or not. Paraganglioma is a somewhat rare neuroendocrine tumor that most often arises from the paraganglion tissues of the adrenal glands. Only in a tenth of cases, extra-adrenal localization may occur, of which 85% reside in the abdomen, and only 3% occur in the head and neck region . UsuallyOne of the chronic inflammation patterns that occurs when the complete clearance of antigenic stimuli is not achieved by the cellular immune system, is granulomatous inflammation, such as that observed in sarcoidosis . Non-necIt is crucial to distinguish SLGIs from actual sarcoidosis, as misdiagnosis may lead to severe consequences . Such phThe present study describes a case with the first reported association of a CBP with SLGI in the absence of any criteria of systemic sarcoidosis or other SGLI-associated conditions.A 54-year-old female patient visited Smart Health Tower  with the presentation of anterior neck swelling for a period of 27 years without any other associated symptoms. She was a married housewife and did not have a history of smoking.Upon examination of the swelling and upon inspection, a grade 3 multinodular goiter (MNG) was suspected as the patient had a thick neck mass visible from a distance of 5 meters, and by palpation, the enlargement was noted to be firm. In addition, a right-side lateral neck mass was observed, which was firm on palpation and movable side to side, but not vertically.Routine laboratory investigations mostly revealed normal findings. However, the patient had decreased thyroid stimulating hormone levels (<0.4 mIU/l), indicating toxic MNG. An ultrasonography revealed MNG with retrosternal extension and a solid lesion on the right side of the neck measuring 40x30x22 mm, which was suggestive of a CBP. Further imaging diagnosis via a computed tomography scan also revealed the presence of MNG in both thyroid lobes, with the largest lobes measuring 75x47 and 87x45 mm on the right and left side of the thyroid, respectively, and a lateral solid hypervascular mass between the internal and external carotid arteries (data not shown).Under a general anesthesia, in a supine position, and via a collar incision, a total thyroidectomy was performed for the patient while preserving the parathyroid gland, and the other cervical neck mass was also resected via another longitudinal incision. A histopathological examination was performed for both masses. Sections from the thyroid gland revealed multiple nodules of different sizes composed of hyperplastic thyroid follicles arranged as large follicles, filled with colloid material, and associated with cystic changes, hemorrhage, fibrosis, cholesterol cleft formation and calcifications, indicating MNG (data not shown).For histopathological analysis, the sections (4-µm-thick) were paraffin-embedded and fixed with 10% neutral buffered formalin at room temperature for 24 h. The sections were then stained with hematoxylin and eosin (Bio Optica Co.) for 1-2 min at room temperature. They were then examined under a light microscope (Leica Microsystems GmbH). Sections from the right-side cervical mass revealed a well-demarcated mass composed of nests and sheets of round-polygonal cells with abundant eosinophilic granular cytoplasm in a hyalinized vascular stroma, focal areas of atypia and focal heavy lymphoplasmacytic infiltration, with the presence of multiple, well-formed, small-medium size, non-necrotizing epithelioid granulomas associated with multinucleated giant cells, confirming the diagnosis of CBP with SLGI and focal lymphoplasmacytic infiltration .The surgery was uneventful, and the patient was discharged in good health. Following a follow-up period of 6 months by ultrasound, the patient was in good health without any sign of recurrence.Non-necrotizing epithelioid cell granuloma, identical to that observed in systemic sarcoidosis, is a rare, yet well-reported phenomenon found in association with various primary neoplasms, infections, drugs  and inorganic substances . When thParagangliomas are a family of sympathetic and parasympathetic paraganglionic tumors. The sympathetic types originate from within the abdomen and adrenal glands, which are referred to as abdominal paraganglioma and pheochromocytomas, respectively. By contrast, the parasympathetic types mainly arise from the head and neck region ,13.The carotid body is a chemoreceptor organ that is highly vascularized , reddish brown in color, and located within the adventitia posteromedial to the common carotid artery bifurcation. Its role involves the autonomic regulation of temperature, cardiovascular, respiratory systems, and acute adaptation to fluctuating concentrations of oxygen, carbon dioxide and pH. It consists of sustentacular cells and chief cells derived from the neuroectoderm and neural crest cells, respectively. Tumors originating from the chief paraganglia cells are termed CBP . Even thCBPs have been reported to be more prevalent among females and are most often observed in the third to the sixth decade of life. The neoplasm usually presents as a non-tender, slow-growing mass, and rarely does the tumor demonstrate a bruit/thrill or transmit a carotid pulse. The tumor may encase the external and internal carotid arteries as it increases in size, although it does not narrow them. Even though CBP is often asymptomatic in the initial phase, due to its proximity to the adjoining vessels and nerves, symptoms may manifest with an increase in size, such as a hoarseness of voice, odynophagia, dysphagia and other cranial nerve deficits. Hypertension, sweating and headaches may also be observed in some patients as a result of the secretion of vasoactive catecholamines by the CBP ,15. ThesUpon a histological examination, CBPs have a characteristic growth pattern known as ‘zellballen’, an organoid or well-developed nested growth pattern of the tumor cells with a stromal component between fragile fibrovascular tissue and supporting sustentacular cells along the edges of the zellballen or cell nests. The tumor cells are mostly chief cells with dispersed chromatin, hyperchromatic, round nuclei and an abundant granular cytoplasm that may be either basophilic to eosinophilic in color ,15. AlthA number of granulomatous conditions are able to mimic sarcoidosis, clinically and histologically, including sarcoid-like granulomatous reactions, infectious granulomatous diseases, granulomatous drug reactions, neoplastic disorders, immunodeficiencies and systemic disorders with granulomatous characteristics (Rosai-Dorfman disease and Blau syndrome) ,16. DistThe first case of SLGI was reported by Wolbach in 1911. Since tIn patients with no history of sarcoid disease, non-necrotizing epithelioid cell granulomas may rarely occur within tumors. The pathogenesis of SLGIs remains to be fully established. It has been reported that it may occur as the result of soluble tumor antigens or cancer-related antigenic factors being shed into the blood, leading to immunological hypersensitivity and granulomatous inflammation .Histologically, SLGIs are similar to sarcoidosis granulomas. They are comprised of well-defined non-caseating granulomas with the focal accumulation of multinucleated giant cells and epithelioid cells ,9. UsualThe presence of SLGI is an indicator of an immunological response of macrophages by activated T-lymphocytes to a neoplasm. Even though the presence of T-lymphocytes should translate to a protective role and better prognosis, currently, the prognostic value of SLGIs is not yet well understood . It has In conclusion, SLGIs accompanying a paraganglioma is an extremely rare event that has not previously been reported, at least to the best of our knowledge. The case described in the present study is the first to be reported; there was no evidence of systemic sarcoidosis or tuberculosis. Due to its rarity, it is difficult to conclude if it confers a better prognosis or not.


Adjuvant treatment options were discussed, and active surveillance was chosen. Two years later, he presented with urinary retention alternating with pollakiuria, a feeling of incomplete bladder emptying, dyspareunia, and anejaculation. A rectal examination documented an enlarged, nodular, painful prostate. Blood and urine analyses, including serum tumor markers, were unremarkable. Pelvic magnetic resonance (MR) documented a central, nodular, solid, hypermetabolic, prostatic tumor with a size of 40x50x25 mm, invasion of the right seminal vesicle, right anterolateral wall of the rectum, and postero-inferior bladder wall, and an absent lymph node and visceral disease. A transrectal ultrasound-guided (TRUS) biopsy documented prostatic metastasis of the seminoma. The patient was treated with four cycles of bleomycin, etoposide, and cisplatin (BEP) chemotherapy (ChT) with a complete  response. After five years of follow-up, he remains asymptomatic without a recurrence of the disease.We report the case of a 32-year-old male diagnosed with a left-sided testicular seminoma treated with radical inguinal orchiectomy and staged as pT1bN0M0S0 ( Testicular germ cell tumors (GCTs) are the most frequent solid tumors in young men between 25 and 35 years old, accounting for 1-2% of all types of cancer in men. The majority are stage I seminomas, which are associated with a very good prognosis regardless of the treatment approach [A 32-year-old male with a past medical history of occasional hematospermia and two previous episodes of orchiepididymitis presented with an enlarged left testis. Ultrasonography of the left testis documented multiple nodular, hypoechogenic, and hypervascularized lesions, the largest measuring 11.7 mm  and beta-human chorionic gonadotropin (Beta-HCG) were normal, and lactate dehydrogenase (LDH) was 198 UI/L Table .The patient underwent a left radical inguinal orchiectomy with the placement of a testicular prosthesis. Histopathology analysis documented a classic, pure seminoma, 30 mm of the major axis, with rete testis invasion but without vascular invasion and free surgical margins (pT1bN0M0 - stage IA). After discussing all adjuvant treatment options, a decision for active surveillance was made with serial tumor markers and imaging.Two years later, he presented with a two-week duration of urinary retention alternating with pollakiuria, a feeling of incomplete bladder emptying, dyspareunia, and anejaculation. The digital rectal examination showed an enlarged, nodular, and painful prostate. Blood tests documented a normal leucocyte count, CRP 0.5 mg/dL, and serum creatinine 1.01 mg/dL. Urinalysis showed moderate hematuria and a negative bacteriologic exam. Tumor markers were prostate-specific antigen (PSA) 3.17 ng/dL, LDH 268 UI/L and normal AFP, Beta-HCG, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone (Table Pelvic magnetic resonance (MR) documented a central nodular solid prostatic mass, 40x50x25 mm, adjacent to the urethra with direct invasion of the right seminal vesicle and no clear cleavage plane with the right anterolateral wall of the rectum Figure .On positron emission tomography CT (PET-CT), the prostatic mass measured 49x61x34mm and had high metabolic activity  18.87), extending to the anterior rectal wall, posteroinferior bladder wall, and the base of both seminal vesicles, and no distant metastases  biopsy was performed and was consistent with prostatic metastasis of seminoma, as immunohistochemical staining of tumor cells was positive for PLAP, CD117, and vimentin and negative for AE1/AE3, PSA, chromogranin, and synaptophysin. Ki67 IHC stain depicted a high proliferative index (90%) Figure .After a multidisciplinary team discussion, treatment was started with bleomycin, etoposide, and cisplatin for four cycles, with complete resolution of symptoms after the first cycle. Four months later, the PET-CT and pelvic MR documented a complete imagiologic and metabolic response Figure .TRUS was done to confirm the complete pathologic response. After five years, the patient maintains regular active surveillance with periodic clinical examination, TAP CT, and tumor markers , without recurrence of the disease.Testicular stage I seminomas are the most frequent presentation of GCT in young men, with a cancer-specific survival of more than 94%, regardless of treatment approach. After radical inguinal orchidectomy, most men remain on active surveillance for at least five years without recurrence . Based oThe metastatic spread of testicular GCTs is thought to occur through the lymphatic system to the retroperitoneal lymph nodes. Visceral metastases, when present, involve most often the lungs, liver, and brain. In the case reported, the patient presented with a painful prostatic mass suggestive of a prostatic abscess, but a neoplastic etiology could not be excluded. Prostate adenocarcinoma, although more common in older men (median age at diagnosis of 68 years), is diagnosed below age 50 in 10% of cases in the USA, doubling the proportion of cases diagnosed in 1995 when PSA screening started being implemented. These cases diagnosed at a younger age have a higher risk of metastatic disease and higher mortality compared with older age groups [With a previous diagnosis of testicular seminoma, young age, and normal serum PSA, after exclusion of prostate infection, prostate metastasis from testicular seminoma becomes the most likely diagnosis. Primary extragonadal GCTs (EGGCTs) are rare tumors with an incidence of 1,8-3,4/million, accounting for 1% to 3% of GCTs. They can occur in almost any midline location, from the brain to the coccyx, being more frequent in the anterior mediastinum, retroperitoneum, and brain . AlthougThe diagnosis of EGGCTs is made by histology and has implications for prognosis and therapeutic approach. Due to the rarity of EGGCTs, primary testicular GCT must be excluded, and histological evaluation is required to exclude undifferentiated carcinomas or other cancers. Non-seminoma GCT (NSGCT) accounts for 60% of primary EGGCT in adults and presents in midline locations ,7. HowevIn the past, complete surgical resection of the tumoral masses was the standard therapy for EGGCTs, which was associated with a poorer prognosis, particularly in mediastinal EGGCTs and EGGCTs with NSGCT components. The introduction of cisplatin-based ChT has dramatically improved the prognosis of these patients and made cisplatin-based ChT the treatment of choice for advanced GCTs . RadicalThe cases of prostate EGGCTs (primary or metastatic) reported in the literature were mainly treated before 2000, when complete surgical resection with pelvic exenteration was the standard of care. More recent cases were treated primarily with cisplatin-based ChT and underwent surgical resection only if residual lesions persisted (as in testicular GCTs), avoiding the unnecessary morbidity of surgery in patients without evidence of residual tumor -17. In tGCTs have a good prognosis regardless of primary and stage of diagnosis. Seminomas have a better prognosis than NSGCT, with a high rate of cure and longer survival.The metastatic spread of testicular GCTs occurs through the lymphatic system to the retroperitoneal lymph nodes. Visceral metastases, when present, involve mostly the lungs, liver, and brain. Cisplatin-based ChT followed by surgery of residual masses is the standard-of-care treatment of advanced disease with a possible cure.


Liver tumors with liver abscesses are unusual and rarely reported. In particular, studies of intrahepatic cholangiocarcinoma with liver abscesses due to hepatic actinomycosis have not been reported.A 73-year-old woman presented with swelling of the right hypochondrium. Computed tomography revealed a mass lesion that was continuous with the abdominal wall in the right lobe of the liver, suggesting a liver tumor invading the abdominal wall. A liver biopsy revealed intrahepatic cholangiocarcinoma with a liver abscess. The histopathological specimen contained bacterial masses of actinomycosis, and the cause of the liver abscess was determined to be hepatic actinomycosis. As a result of percutaneous drainage and antibiotic therapy, the part of the tumor attached to the abdominal wall disappeared; therefore, we assumed that most of the lesion was not cholangiocarcinoma but a liver abscess due to hepatic actinomycosis. Radical surgery for residual intrahepatic cholangiocarcinoma was performed after chemotherapy. Currently, the patient is alive without recurrence 2 years and 9 months after the operation.We encountered a difficult-to-diagnose case of intrahepatic cholangiocarcinoma with a liver abscess due to hepatic actinomycosis. A needle biopsy allowed early diagnosis and percutaneous drainage was an effective treatment. Liver tumors with liver abscesses are rare, except as a rare complication of cancer therapies such as arterial embolization or percutaneous local therapy , 2. Amon3 and C-reactive protein of 8.3 mg/dL. All tumor markers  were within reference ranges.A 73-year-old woman presented with swelling of the right hypochondrium. The patient had a medical history of high blood pressure. Physical examination confirmed a subcutaneous mass in the right hypochondrium. No obvious tenderness or peritoneal signs were observed. Body temperature was 36.5 °C, blood pressure was 150/95 mmHg, and heart rate was 129 bpm. A blood test on admission (Table A contrast-enhanced computer tomography (CT) scan showed a 68-mm mass lesion in the S5 of the right lobe of the liver. In the late phase, a strong enhancement effect was observed at the margin of the tumor. A 70-mm mass with poor contrast enhancement was found on the side of the abdominal wall. Because the mass was continuous with the liver, we suspected invasion of the abdominal wall by a hepatic malignant tumor such as intrahepatic cholangiocarcinoma Fig. . ContrasBased on the imaging findings, an invasion of the abdominal wall by a malignant hepatic tumor was suspected. However, a liver abscess could not be ruled out. A needle biopsy was performed for diagnostic purposes on the 14th day of hospitalization.Fusobacterium sp. but not actinomycetes. A hepatic abscess associated with hepatic actinomycosis was diagnosed because bacterial masses of actinomycetes (sulfur granules) were observed in the pathological histopathology  were administered to treat intrahepatic cholangiocarcinoma from the 56th day of hospitalization and CT imaging was performed again. A contrast-enhanced CT image on the 155th day of hospitalization showed that the hepatic mass in the late phase shrunk considerably to 27 mm in size, although the contrast effect remained  were performed. Only mild adhesions were observed between the liver and abdominal wall, and no disseminated lesions were seen in the abdominal wall or the intraperitoneal cavity. A rapid pathological diagnosis of the No. 12 lymph node and intra-abdominal nodule confirmed the absence of cancer metastasis.Histopathological findings showed an old inflammatory focus forming scars on the margin of the liver and a well-differentiated intrahepatic cholangiocarcinoma measuring 1.8 × 1.5 cm that partially overlapped with inflammatory foci. No invasion into the surrounding liver parenchyma, vascular invasion, extension to the serosal membrane, or invasion into the bile duct were observed . The patient has been recurrence-free without adjuvant chemotherapy for 2 years and 9 months after surgery.In this case, intrahepatic cholangiocarcinoma formed a mass resembling a liver abscess due to hepatic actinomycosis—an extremely rare condition that, to the best of our knowledge, has never been reported before. In general, malignant liver tumors with liver abscesses are misdiagnosed as refractory liver abscesses and cancer treatment is often delayed . WithoutKlebsiella pneumoniae and Escherichia coli [In general, pyogenic liver abscesses are caused by enteric bacteria such as hia coli , 7. ActiActinomyces israelii, an anaerobic, Gram-positive bacillus that normally resides in the oral cavity and gastrointestinal tract. Actinomycosis is observed in every organ; however, more than half of cases occur in the head and neck region and approximately 20% of cases occur in the abdomen. Hepatic actinomycosis accounts for approximately 5% of all actinomycoses and can cause liver abscesses [Actinomycosis is a chronic pyogenic granulomatous disease mainly caused by bscesses –10. Imagbscesses , 9; a debscesses . MRI shobscesses , 11. Hepbscesses . AlthougHepatic actinomycosis is often misdiagnosed as hepatic malignancy and is diagnosed by postoperative histopathological examination . In thisNo consensus exists on the treatment of actinomycosis. Long-term high-dose administration of β-lactam antibiotics such as penicillin is recommended , whereasTo the best of our knowledge, no study of intrahepatic cholangiocarcinoma with liver abscesses due to hepatic actinomycosis has been reported. Furthermore, this case was unusual and interesting because hepatic actinomycosis and intrahepatic cholangiocarcinoma were not two separate lesions but occurred within the same mass.Immunosuppressive status is a known risk factor for invasive actinomycosis . BecauseThe percutaneous biopsy performed in this case may increase the risk of forming a disseminated lesion of the malignant tumor , 5. In tIn this case, a percutaneous biopsy was useful for both diagnosis and treatment. Percutaneous biopsy enabled an early and accurate diagnosis and resulted in a good prognosis despite a complicated case of hepatic actinomycosis and intrahepatic cholangiocarcinoma.We encountered an extremely rare and difficult-to-diagnose case of intrahepatic cholangiocarcinoma with a liver abscess due to hepatic actinomycosis. A needle biopsy was useful in providing an early diagnosis and percutaneous drainage was an effective treatment.


The high incidence of HIV infection in South Africa has been associated with a proportional increase in AIDS-defining cancers, including non-Hodgkin’s lymphomas (NHL). Intussusception is a rare presentation of NHL, accounting for 1% – 5% of all cases of small bowel obstruction.To our knowledge, this is the first reported case of B-cell NHL presenting with intussusceptions and small bowel obstruction in South Africa. The incidence of AIDS-defining cancers, known to be Kaposi sarcoma, non-Hodgkin’s lymphoma (NHL) and cervical cancer, is much higher in individuals living with HIV than in the general population.4 The incidence of NHL in the general population is estimated at 18.6 of 100 000 individuals5 while in people living with HIV the incidence rates of 205 out of 100 000 persons for those on combination antiretroviral therapy (cART) and 463 out of 100 000 persons for those not on cART.6Sub-Saharan Africa records the highest HIV infections globally.7 The gut is the most common extranodal site affected by lymphoma. Gastrointestinal lymphoma is usually because of secondary metastatic nodal disease affecting the stomach, small bowel and colon.7 The ileum is the most common site affected by small intestinal lymphoma, followed by the jejunum and duodenum.8 Intussusception is a rare presentation of NHL and is often seen in the case of a diffuse large B-cell NHL.8 Adult intussusception represents 5% of all intussusception cases and 1% – 5% of all cases of bowel obstruction.9Non-Hodgkin’s lymphoma is the second most common neoplasm in people living with HIV. Diffuse large B-cell NHL is the most usual histological type.6 cells/µL with an undetectable viral load at presentation. Her cART comprised daily fixed combination of tenofovir, emtricitabine and efavirenz for the past four years. She reported no fever, weight loss or night sweats. On physical examination, she had an elevated blood pressure of 156/106 mmHg and a tachycardia of 150 beats per minute; however, she was apyrexial with a normal respiratory rate. Her abdomen was markedly distended, firm and generally tender. She had involuntary guarding and rebound tenderness. Digital rectal examination revealed an empty rectum. Per vaginal examination and assessment of other systems were unremarkable.A 23-year-old female presented with features of small bowel obstruction. She complained of vomiting for the past 3 days, failure to pass stools for 5 days and abdominal distension. She was diagnosed with HIV four years earlier, and had a CD4 count of 294 x 10The patient’s biochemistry results are shown in Air fluid levels were demonstrable on erect abdominal X-rays see . ComputeAfter fluid resuscitation, the patient was prepared for an exploratory laparotomy. Intraoperative findings included a reducible intussusception at the ileo-caecal juncture and another at the mid-jejunum, which needed a wedge resection and a jejunostomy see . Bilater10 However, our patient presented late with features of small bowel obstruction and peritonism. Peritoneal signs and elevated septic markers were probably attributed to ruptured granulomas with intra-abdominal pus. The patient had anaemia with the haemoglobin of 4.7 g/dL. During the post-operative period in the ward, bone marrow investigation was performed and confirmed anaemia of chronic disease and tumour infiltration.The clinical manifestations of primary intestinal lymphoma include nausea and vomiting, insidious abdominal pains, ‘B’ symptoms , abdominal mass and haematochesia.11 Diffuse large B-cell NHL is the commonest HIV-associated lymphoma.12 The development of HIV-associated lymphomas includes an interaction of different biologic variables, such as chronic antigen stimulation, co-infection with oncogenic viruses, genetic abnormalities and cytokine dysregulation, which together influence the likelihood of developing a specific type of lymphoma.12Lymphomas are a diverse spectrum of neoplastic disorders that originate from either T- or B-lymphocytes. Broadly speaking, they are divided into Hodgkin’s and non-Hodgkin’s lymphomas.13 Non-Hodgkin’s lymphoma and Kaposi’s sarcoma may lead to intestinal obstruction from an intraluminal space occupying mass or by acting as a lead point for intussusception.13 Abdominal mycobacterial infection can cause obstruction by fibrotic adhesions due to terminal ileitis.13 Cytomegalovirus14 and cryptococcal small bowel obstruction15 have also been described. However, other causes of obstruction such as post-surgery small bowel adhesions and herniae should still be considered.13 In this case our patient presented with with two sites of intussusceptions with NHL granulomas acting as lead points.Bowel obstruction in the context of HIV poses a unique challenge to the treating physician who must contemplate the possibility of opportunistic infections and malignancies, which may not be prevalent in the general population.16 This is postulated to be because of deranged bowel peristalsis at the site of the lesion, which forms a lead point for the intussusceptum.16 A lead point may be a tumour, polyp, Meckel diverticulum or even an appendix stump.16 In patients with no obvious identifiable lead point, intussusception may be from submucosal bowel oedema, fibrous adhesions or irregular intestinal contractions.16Intussusception occurs when a more proximal segment of bowel (intussusceptum) folds into the lumen of an adjacent distal segment of another bowel (intussuscipiens).10 It carries the advantage of being relatively cheap, non-invasive, and readily available.10 The classic ultrasonographic features of intussusception include target sign or doughnut sign on axial view as well as pseudo-kidney sign or hayfork sign on longitudinal plane.10 Computed tomography scan has a superior value in defining the location and in characterising the tumour and its association with surrounding structures.10 It is a modality of choice for staging the disease.10 Surgery is indicated for the management of intussusception and/or bowel obstruction.10 An emergency laparotomy was performed as the patient in the case presented acutely with a complicated small bowel obstruction. Surgery also offers the opportunity to biopsy the lesion for diagnostic purposes.10 The gold standard of treatment of lymphoma is chemotherapy, while surgery plays a role in the management of associated complications, such as bowel obstruction.10 The use of the regimen cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) is warranted in both immunosuppressed and immunocompetent patients.10While abdominal ultrasound is considered comparable to CT scan for sensitivity and specificity, it is operator dependent.HIV is a major cause of morbidity and mortality in South Africa. However, widespread cART availability has reduced the rate of new transmission and complications of HIV. The case highlights how HIV-related lymphomatous granulomas, acting as lead points, may cause intussusception and subsequent bowel obstruction.The presentation of intussusception from granulomatous lesions of lymphoma is uncommon with few reported cases internationally. To our knowledge, this is the first reported case in South Africa of B-cell NHL presenting with two sites of intussusceptions that are located at the ileo-caecal junction and the mid-jejunum. The incidence of bowel obstruction caused by intussusception in people with HIV is undetermined in South Africa. Therefore, this case report serves as a foundation for further research on the topic.


Abdominal distension in children can be caused by fluid accumulation due to ascites or large cysts.A 25-month-old girl was brought to the pediatric gastroenterology clinic with the chief complaint of nontraumatic acute abdominal pain. She had undergone paracentesis last year with a diagnosis of suspected ascites in another medical clinic. Moreover, a CT scan following paracentesis was reported to be normal. After a few months, she gradually developed abdominal distension again. Diagnostic evaluations along with biochemical parameters and imaging strongly suggested the presence of a cyst. The large mesenteric cyst was totally removed by surgery.In conclusion, in the face of recurrence of abdominal fluid accumulation, mesenteric cysts should be considered despite the fact that abdominal CT scan is normal after paracentesis. Both increased intra-abdominal volume and the abnormal somatic response contribute to visible abdominal distension . Indeed,Ascites is defined as the pathologic accumulation of fluid within the peritoneal cavity. Well-characterized causes of ascites in infants and children include genitourinary disorder, neoplasm, hepatobiliary disorders, cardiac disorders, serositis, and metabolic disease . HoweverIn Torino, Italy, Ferrero et al.  studied They usually emerge in early childhood as a palpable abdominal mass. Note that approximately 60% of these cysts appear before the age of 5 years. These large cysts are routinely found in the small bowel mesentery; however, they may occur anywhere in the gastrointestinal tract ,5. The present report introduces a patient with a lymphangioma cyst since, as a cause of abdominal pain and swelling, cysts misdiagnosis with ascites as the first differential diagnosis and thereby performing the inappropriate therapeutic intervention, such as paracentesis can lead to cyst recurrence and abdominal swelling. Even, it may lead to life-threatening complications, including bleeding, torsion, or lymphangioma rupture , especiaA 25-month-old girl was presented with the chief complaint of progressive abdominal swelling and pain about one year ago . FollowiPhysical examination of the patient showed normal and stable conditions. Additionally, no lower extremities edema was observed. The abdomen was distended with a non-tender mass. Laboratory tests, including complete blood cell count, the white blood cell count, hematocrit, and platelet, the total protein and albumin, electrolytes, and liver function tests, along with urine analysis and stool exam, Amylase, lipase, anti-tissue transglutaminase antibody immunoglobulin A, and serum IgA, the erythrocyte sedimentation rate and C-reactive protein were within normal ranges. Furthermore, her echocardiography did not show any abnormal findings.The ultrasound and spiral abdominopelvic CT scan with oral and intravenous contrast showed some disseminated homogenous fluids in the abdominal cavity. This enormous cystic lesion pulls away from the hallo viscous to the left side ). SecondThe cyst was totally excised, and an omentectomy was performed subsequently. After surgery, the patient felt full recovery and was ultimately symptom-free. The histology report also suggests a 9*6*0.8 cm mesenteric cyst to be lymphangioma, with endothelial cell lining and a wall containing lymphatic spaces, lymphoid tissue, and smooth muscle . In the Despite fluid drainage and improvement of abdominal symptoms, the abdominal swelling and abdominal pain recurred after one year, and the patient was diagnosed with a mesenteric cyst. Drainage is among the less recommended methods in the treatment of mesenteric cysts, which is associated with the risk of recurrence and the risk of rupture; thus, in this case, the patient's improvement following drainage was probably the reason for the normal CT scan and non-recurrence of abdominal swelling for up to a year.History, physical exams, and paraclinical tests can be useful for the diagnosis of ascites. Causes of ascites are classified as cardiac, renal, hepatic, vascular, and malabsorption. We did not find any findings in favor of ascites in this patient. The drained fluid was a cyst fluid, not ascites; though in that center, the fluid was considered a high SAAG ascites, yet no positive finding was found in favor of ascites. Note that mesenteric cysts can mimic the symptoms of ascites . The preCystic lymphangioma is a slow-growing uncommon congenital benign tumor. Most lymphangiomas may be found in the head or neck, while intra-abdominal sites such as omentum, mesentery, and retroperitoneum are unusual . These cThe recent positive abdominal CT scan after the normal CT scan report after conducting paracentesis attracted our attention to a cystic lesion. In the cases of huge lymphangiomas, it is somewhat difficult to distinguish cystic lesions from severe ascites. Differentiating features suggesting ascites rather than lymphangioma include separation of bowel loops, fluid collecting in the perihepatic spaces and cul-de-sac, and lack of septations ,10; thouLong-term follow-up with ultrasonography plays a pivotal role, particularly where complete excision has not been achieved, considering the risk of recurrence (9). In conclusion, in the face of recurrence of abdominal fluid accumulation, mesenteric cysts should be considered despite the fact that abdominal CT scan is normal after paracentesis.


Seborrheic keratosis, one of the most common lesions of the epidermis, is rarely seen on mucosal surfaces. We report a case of a distinctive epithelial neoplasm of the esophagus showing close resemblance to seborrheic keratosis that was resected with endoscopic submucosal dissection. A 65-year-old patient’s previous esophageal biopsy showed suspicious low grade dysplasia and the patient was referred for endoscopic submucosal dissection of a flat lesion in the mid-esophagus. Macroscopic examination revealed a well circumscribed, pigmented and elevated lesion with a diameter of 20 mm. Microscopically, the lesion was well circumscribed, with plaque-like elevation, and showed hyperkeratosis, acanthosis, and papillomatosis. Broad coalescing solid sheets and interconnecting trabeculae of basaloid cells were the consistent feature throughout the lesion. Squamous eddies and occasional central keratinization were present. Mitotic activity and koilocytes were not identified. Immunohistochemically, the lesion showed diffuse nuclear positivity with p63 and negativity with p16. Ki-67 index was confined to the basal cell layer. With the help of histopathologic and immunohistochemical findings, we diagnosed this morphologically benign case as “seborrheic keratosis-like lesion of the esophagus”. It should be kept in mind that seborrheic keratosis-like lesions might be rarely seen on mucosal surfaces such as the esophagus. Endoscopic submucosal dissection is a new, curative, and safe endoscopic resection technique in en-bloc resection of superficial esophageal lesions. To our knowledge, this is the first case of the aforementioned lesion in the esophagus being resected with endoscopic submucosal dissection. Although application of ESD to the esophagus is limited in early stage esophageal neoplasia because of its greater technical difficulty, it avoids the high morbidity and mortality rates of surgical treatment  was shown in two of these cases . Howeveren bloc resections and the recurrence rates are lower (ESD is an effective method for neoplastic lesions of the esophagus and it is a safe treatment modality in the management of early esophageal squamous cell neoplasms. However, great skill in this technique is definitely required . ESD is re lower . A studyre lower .Rare lesions of the esophagus resected with ESD or EMR reported in the literature include Barrett’s esophageal cancer , granulaHerein, we report a case of a superficial esophageal lesion resected with ESD. We diagnosed this morphologically benign case as a “seborrheic keratosis-like lesion of the esophagus” with the help of histopathologic and immunohistochemical findings. To our knowledge, this is the first case of the aforementioned lesion in the esophagus.en bloc resection of superficial esophageal lesions.In conclusion, it should be kept in mind that seborrheic keratosis-like lesions might be rarely seen on mucosal surfaces such as the esophagus and that ESD is a safe procedure in The authors declare no conflicts of interest.


Fibrofolliculomas are benign connective tissue tumours of the hair follicle that typically present as multiple lesions over the head and neck. A solitary fibrofolliculoma is a rare entity and has not been previously described in the canthal region. The authors report an unusual case of a 43-year-old female who was found to have a solitary fibrofolliculoma located in close proximity to the medial canthus following an excision biopsy. Whilst rare, fibrofolliculomas should be considered in the differential diagnosis of an eyelid lesion. Fibrofolliculomas are benign, perifollicular connective tissue tumours that present as clinically asymptomatic, skin-coloured, dome-shaped, smooth lesions across the head and neck. They were first reported by Birt et al. in 1977 in a case series of 15 people with skin lesions. Histologically, they can be described as abnormal follicles of hair with differentiation of its root sheath and associated infundibular epithelial proliferation .A solitary fibrofolliculoma, however, is a rare entity and was first reported in the literature in 1984. In contrast to multiple fibrofolliculomas, a solitary lesion by itself does not have a genetic predisposition and is not associated with other cutaneous abnormalities . There aA 43-year-old female, who worked as a nurse, was referred by her general practitioner (GP) to the oculoplastics service during the COVID-19 pandemic. She had a concern about a lump located below the right lower eyelid and in close proximity to the medial canthus, which had been present for a few months. The referral stated that the lump had been getting larger, and was causing the patient discomfort during the day when they had to wear a mask at work.By the time this lady was seen in the oculoplastic clinic, the lesion had been present for 12 months. She denied any bleeding, itching, or pain and reported that it was occasionally red. She had no other past ocular history and her past medical history included asthma and hypothyroidism.On examination, the lesion was described as a 3 mm cystic lesion Figure .The rest of her ocular examination was unremarkable. Based on these findings, a possible diagnosis of a cyst of Zeiss was suggested. Since the location of the lesion was susceptible to trauma, she was listed for an excisional biopsy and subsequently underwent a right medial canthal lesion biopsy under local anaesthesia. The histology referral specifically queried whether the specimen was a naevus or a basal cell carcinoma (BCC), which represents possible differential diagnoses. The final histology result reported a 2 mm skin nodule with skin sections of underlying fibrofolliculoma with no dysplasia, melanocytic proliferation, or malignancy seen. The histology slides from this patient show skin with underlying circumscribed unencapsulated lesion composed of epidermal strands set in a fibrotic stroma, also known as a hamartoma of the hair follicle Figures .The patient was followed up in an outpatient clinic where the benign nature of the diagnosis was explained to her.Cases of a solitary fibrofolliculoma on the eyelid are rare; since first being reported in 2007, there have been a total of four cases that have been published in MEDLINE Table .We reviewed the previously published cases and found that the age of patients ranged from 37 years to 72 years with no clear gender preference. There was no clear trend towards either eyelid, with two of these cases reported on the upper eyelid and two on the lower eyelid. Our report describes the first case of a solitary fibrofolliculoma found in the canthal region. Amongst the published case reports, symptom duration varied from a few months to several years. The commonest diagnostic and treatment modality, including the preferred option in the present case, was excision biopsy.The majority of eyelid tumours are of cutaneous origin, which includes benign epithelial lesions, BCCs and melanocytic tumours . FibrofoSince solitary fibrofolliculomas are rare and need histological assessment to confirm diagnosis, they can be easily misdiagnosed without biopsy as could have been in this case. Chang et al. described this condition in the case of a 37-year-old female patient, noting that the lesion was present for five years and was initially misdiagnosed as a chalazion . This keTo conclude, we present a case of a lesion arising in close proximity to the medial canthus showing the histological features of a fibrofolliculoma. Whilst rare, a diagnosis of solitary fibrofolliculoma may be included in the differential diagnosis when a similar lesion is observed. An excision biopsy with histological assessment is an effective way to confirm the diagnosis, as well as exclude possible malignant causes.


Consent was provided by the patient for publication of case details and images.A 75-year-old Black woman presented with a large mass on her lower lip. The mass had been present for 6 months and had rapid growth. She denied any associated symptoms aside from tenderness to palpation and occasional minor bleeding secondary to dryness and fissuring of the lower lip. The patient reported that she was otherwise in good health, noting a history of well-controlled hypertension treated with ≥12.5 mg of hydrochlorothiazide (HCTZ) for >10 years.2 exophytic tumor with hyperkeratotic scales was found to be located on the lower vermilion lip, spanning at least 70% of its length . Given the tumor size and perineural involvement, she was staged at T2b. Forty-gene expression profile testing was indicated given high-risk tumor factors. It demonstrated a class 2A result, signifying an 80.5% 3-year metastasis free survival rate. She was referred to radiation oncology for adjuvant radiation therapy of the lip.The patient underwent 2 Mohs stages to achieve clear margins, with a final wound defect of 4.6 × 2.2 cmAlthough SCC is a relatively common cancer of the lip, large tumors are rare. A review of 581 cases of lip NMSC revealed that only 9.4% of SCCs are >3 cm, with the largest reported to be between 6 and 7.9 cm.,,,The overall prognosis for lip SCC is favorable, with a ∼90% 5-year survival rate across numerous studies.,Black women appear to be the least common group to present with lip SCC, accounting for ∼1 in 1000 lip SCC cases.None disclosed.


Neoplasms of the salivary glands are of rare incidence, have a vague presentation, and follow a complex long-term clinical course. Both minor and major salivary glands have been implicated in dysplastic transformation, with parotid gland tumors being the most notable. Most of these tumors are benign in nature and are typically diagnosed and classified based on their histopathological presentation. In this report, we exhibit a rare case of basal cell adenomas (BCA), localized to the right parotid gland, in a 69-year-old male patient. Volume acquisition computed tomography (CT) imaging of the region was obtained with and without contrast, with relative reconstruction in both the coronal and axial planes. A soft tissue mass of 5 cm in diameter was detected in the superficial lobe of the right parotid gland. Fine needle aspiration (FNA) with ultrasound guidance revealed a population of basaloid cells that is monomorphic with minimal nuclear atypia and scattered fibrillary matrix. Thereafter, the patient was treated with partial excision of the right parotid gland under general anesthesia, and the post-operative pathology report confirmed the diagnosis of basal cell adenoma. The patient was doing well post-operatively with no complaints and maintained routine clinic follow-ups. Benign salivary gland neoplasms encompass an array of histopathological presentations and affect multiple sites in the head and neck region. The most commonly affected major salivary gland is the parotid gland, followed by the submandibular and sublingual glands, respectively. Among the minor salivary glands, upper lip neoplasms are the most frequently reported, followed by tumors in the buccal mucosa .The World Health Organization (WHO) classifies benign salivary gland tumors into 11 different types, including basal cell adenoma (BCA). They describe BCA as a benign unspecified entity with an overall incidence rate of 1.1-3.7% .Monomorphic basaloid epithelial cell proliferation constitutes the histopathological hallmark of BCA. Clinically, BCA is typically described as a slow-growing mass that is seldom symptomatic and is freely movable .Adults between their fifth and seventh decades of life are most commonly affected. BCA carries a favorable prognosis in comparison with other salivary gland neoplasms, especially since recurrence is not common. Since BCA and basal cell adenocarcinoma share similar histopathological features, it can sometimes be difficult to distinguish them from one another. However, the latter generally presents with the invasion of the surrounding structures .Here, we report a case of a parotid mass presenting as an asymptomatic swelling histopathologically identified as basal cell adenoma.We report a 69-year-old male, medically free and with no identifiable allergies, who was referred to our otorhinolaryngology (ENT) general clinic for the evaluation of a painless swelling in his right parotid region that had been present for a 10-year period. On further examination, the patient disclosed having no associated symptoms besides the noticeable swelling of his cheeks. There was no history of dyspnea or dysphagia. The patient denied any history of pain, skin color changes, numbness, facial weakness, xerostomia, odynophagia, or other obstructive symptoms.On physical examination, the patient was vitally stable. A single, firm, non-tender swelling of his right parotid region was palpable. It was mobile and not fixed to the underlying structures. On examination of the neck lymph nodes, they were all non-palpable. The facial nerve proved intact, and the rest of the examination pertaining to the head and neck was unremarkable.On multiplanar CT scanning of the head and neck, a unilateral mass of soft tissue density in the right parotid gland arising from the superficial lobe was evident. The mass carried a mean diameter of 5 cm in its greatest dimension Figures -2.The patient was arranged for ultrasound-guided fine needle aspiration (FNA), with three passes of FNA being uneventful. FNA showed basaloid cells to have a monomorphic population with minimal nuclear atypia along with a scattered fibrillary matrix, without mitosis or any tumor necrosis. The features were suggestive of a cellular basaloid neoplasm.The treatment of choice was a right partial parotidectomy under general anesthesia. The surgery was uneventful, and the mass was sent for histopathological examination Figure . The patThe WHO salivary gland tumor classification recognizes the BCA of the salivary glands as an independent entity in its fifth edition . The larThe histological features in our case are consistent with those reported in the literature, showing a population of basaloid cells that are monomorphic with slight nuclear atypia associated with a dispersed fibrillary matrix .Jang et al. reported three cases of BCA involving the parotid gland. Their aim was to describe the appearance of these tumors on computed tomography (CT) and magnetic resonance (MR) imaging. They came to the conclusion that all three studied cases shared the same imaging appearance of being well-circumscribed, having both solid and cystic or pure solid components, and enhancement upon contrast injection. However, not all of them were localized to the superficial lobe; two were located in the deeper portion of the parotid with protrusions toward the superficial lobe . Our casBCA of the parotid gland is a rare tumor with a wide list of differential diagnoses. Its ambiguous clinical picture as an asymptomatic swelling necessitates the need for early recognition, histopathological diagnosis, and therapeutic intervention. Challenges such as delayed presentation and loss of follow-up have made it necessary that physicians be aware of such implications for the health system and the patient's psychosocial status.


Heterotopic gastric mucosa (HGM) in the colon and small bowel is a very rare finding. We report a case of HGM in the rectum of an 8-year-old child with a history of eosinophilic esophagitis after having a colonoscopy to evaluate for inflammatory bowel disease. The colonoscopy was normal except for rectal tissue erythema and edema. Inflammatory bowel disease has been reported in some cases of children with eosinophilic changes of the esophagus. The child had intermittent rectal bleeding thought to be due to constipation. Interestingly, when the patient was placed on a proton pump inhibitor for the treatment of eosinophilic esophagitis, the rectal bleeding decreased. After our patient ceased proton pump inhibitor therapy, he experienced a large amount of rectal bleeding. Histological findings revealed HGM in the colon/rectum. An extensive review of the incidence, diagnosis, and treatment is discussed. Histopathological examination most commonly demonstrates oxyntic-type gastric mucosa.2HGM often occurs as a solitary lesion in the rectum but can be multifocal.We report a case of unusual histological finding of HGM in the rectum in an 8-year-old child after colonoscopy to evaluate for IBD.The patient is an 8-year-old male with a history of constipation, eosinophilic esophagitis (EoE), and failure to thrive, who presented with worsening intermittent hematochezia suspected to be due to constipation. He was initially treated with ranitidine, omeprazole, polyethylene glycol, and a high-fiber diet, with resolution of hematochezia. Regurgitation and reflux continued despite treatment, and EoE was diagnosed at 6 years via upper endoscopy. The patient’s family elected to stop the proton pump inhibitor (PPI) and initiated diet elimination intervention for EoE, which excluded gluten, dairy, soy, egg, nuts, and fish/shellfish. Oral swallowed steroids were not prescribed, as family wanted treatment without medicines. His cough and regurgitation improved on diet, but hematochezia recurred with mucous-filled stools. Differential diagnosis at this time included constipation, fissures, infectious colitis, Meckel’s diverticulum, vascular ectasias, bleeding disorder, rectal ulcers, polyps, and IBD. Stool samples were negative for microorganisms, and calprotectin was normal. Polyethylene glycol was used to rule out constipation and fissures. However, the rectal bleeding worsened with blood dripping down his leg after bowel movements.Helicobacter pylori by Warthin Starry special stain and immunohistochemical staining.Due to worsening hematochezia and mucous-filled stools, repeat esophagogastroduodenoscopy and colonoscopy were performed to evaluate for the etiology of rectal bleeding. The mucosa of the terminal ileum and entire colon was grossly normal, except for edema and erythema of the rectum  without ulceration or nodularity Fig. . HistoloFollowing the discovery of the HGM in the rectum, a Meckel scan was performed with technetium-99m (and priming with the H2 blocker before scan), which did not show abnormal radiopharmaceutical uptake in the descending colon, rectum, or other parts of the gastrointestinal tract. The patient was restarted on PPI, and the family is currently considering their options for treatment of the HGM.7 and may be a source of rectal bleeding in patients with EoE. The recent retrospective case-control study found the prevalence of IBD among pediatric EoE patients to be significantly higher than EoE and IBD alone in the general population .7 This association and other etiologies of rectal bleeding prompted the clinical team to proceed with colonoscopy, leading to the diagnosis of HGM in the rectum. Clinical features of HGM can mimic IBD and may be difficult to differentiate without histological evaluation. Children with HGM presented most often with grossly aberrant mucosa (45%), solitary ulcers (33%), or polyps (22%) endoscopically.8 In a systematic review of 78 cases, only 5 cases reported multifocal localization of HGM.2 Direct histologic evaluation may be the best diagnostic test. Our patient had a negative Meckel scan despite the pathology biopsy showing HGM located in the rectum. False negative scans are possible if the location of HGM is obscured by the bladder or if the size of the HGM is too small.9 Clinicians should recognize that a normal Meckel scan does not exclude small foci of HGM. A Meckel scan in 9 pediatric cases of HGM demonstrated only 3 positive scans with uptake in the rectum.2 From these studies, a Meckel scan may be low yield to identify HGM.Rectal bleeding can be from various causes including anal fissures secondary to constipation, infections, IBD, polyps, and rarely Meckel diverticulum, vascular anomalies, bleeding disorders, and rapid upper gastrointestinal bleeding. However, recent research has shown possible associations between IBD and EoE2 Following surgical excision for larger lesions  or endoscopic removal  in 60 cases, the symptoms did not return after follow-up ranging from 2 to 84 months .2 Pediatric rectal HGM cases in the literature were often treated with transanal surgery.8 At least 4 pediatric cases have also been treated with endoscopic mucosal resection without complications.10Previous studies have shown that PPIs or H2 receptor antagonists can be effective at temporary symptom control or ulcer healing, with many cases ultimately reporting surgical excision of the HGM.2 No pediatric cases of malignancy have been reported. Additionally, HGM has been shown to progress to adenocarcinoma or dysplasia in other organs, such as the esophagus or gallbladder.11 The cause of malignant transformation of HGM is not well understood, with some proposing that H pylori infection is involved and that progression is stepwise from metaplasia to dysplasia to adenocarcinoma.12 Our patient’s tissue sample was negative for H pylori. The prognosis and evolution of HGM in the rectum remains unclear, so endoscopic surveillance may be needed to continue to monitor the affected area if it is not resected. Our patient is currently considering various treatment options and will be monitored by the clinical team closely.There is inconclusive evidence about whether HGM can progress to malignancy, but the potential is present. There are only 3 adult cases in the literature reporting rectal HGM with metaplasia.B.P.-R.M., J.N., and S.K. contributed a significant portion of drafting the manuscript and approved the final draft submitted. M.W. also edited the document. B.P.-R.M. obtained patient data and contributed greatly to the final manuscript. This includes writing and editing of the manuscript. J.N. contributed to pathology figures and writing of the manuscript. S.K. provided supervision, expertise on the topic, idea creation, and writing and editing of the manuscript. M.W. edited the document and provided feedback. All authors read and approved the final manuscript. S.K. is the guarantor of the article.