Tumors of the genital system are common and imaging is of crucial importance for their detection and diagnosis. Several non-neoplastic diseases may mimic these tumors and differential diagnosis may be difficult in certain cases. Misdiagnosing non-neoplastic diseases as tumor may prompt unnecessary medical treatment or surgical interventions. In this article, we aimed to present the imaging characteristics of non-neoplastic diseases of the male and female genital systems that may mimic neoplastic processes. Increasing awareness of the imaging specialists to these entities may have a severe positive impact on the management of these patients. Genital organs are commonly affected by neoplastic and non-neoplastic diseases in both sexes and imaging plays a crucial role in differential diagnosis.Several infectious and inflammatory disorders may mimic cancer both clinically and radiologically in both sexes.Familiarity with the imaging findings of these different non-neoplastic urogenital disorders may be very helpful for the correct diagnosis.Genital organs are commonly affected by neoplastic diseases in both sexes. In these patients, imaging studies play a fundamental role in the detection, differential diagnosis, staging, and follow-up. It should be noted that several non-neoplastic diseases may also present with similar findings and differentiation from neoplastic diseases may be difficult in some patients. Clinical and laboratory findings may provide additional information in selected cases. Histopathologic confirmation will often be needed for treatment guidance in these patients. The major goal of this paper is to describe various imaging aspects of several non-neoplastic conditions affecting the male and female genital organs.The male genital tract may harbor various non-neoplastic diseases that can mimic malignancy. A comprehensive summary of clinical and radiological findings of tumor mimickers in the male genital tract can be found in Tables Prostate cancer is an extremely common malignancy. Multiparametric prostate MRI has been applied successfully for diagnosis and lesion localization. Typical MRI features of prostate cancer include low signal intensity on T2-weighted (T2W) images with corresponding diffusion restriction. Early phase enhancement is typical on dynamic contrast-enhanced (DCE) T1-weighted (T1W) images, which is another helpful feature for differential diagnosis. Several mimics of cancer should be considered during the interpretation of these studies . Im. Im22]. Malacoplakia is another rare inflammatory disease of the testes which may sonographically mimic testis tumors. It is thought to develop secondary to chronic granulomatous inflammation due to chronic infection . MalacopTesticular abscesses are usually a complication of bacterial epididymo-orchitis. In rare situations secondary infections of pre-existing hematomas or infarct areas have also been reported . US is gAbscesses with minimal cystic content may be difficult to differentiate from testicular neoplasms Fig. . The difTestes may be affected in the course of several different types of vasculitis . PolyartTesticular vasculitis is one of the great mimickers of neoplastic processes. The differential diagnosis may be even more difficult when parenchymal involvement is multifocal. In these patients, lymphoma or metastatic disease to the testes may be considered in the differential diagnosis. Subacute testicular torsion should also be considered .US typically reveals a hypoechoic focal parenchymal lesion with heterogeneous internal echotexture. Color Doppler findings are variable Fig. .Fig. 12ITesticular involvement is rare in patients with IgG4-RD. The involvement pattern may be subclassified as paratesticular and primary testicular involvement. Paratesticular fibrous pseudotumors are rare and may be either solitary or multiple. Histopathologically, they are composed of dense fibrous tissues with inflammatory infiltration of variable severity. Increased number of IgG4 positive plasma cells are typical for histologic diagnosis .Testes themselves may also become involved in the course of IgG4-RD Fig. . There iSarcoidosis is a multisystemic disease characterized by noncaseating granulomas. It is most commonly seen among African Americans and the people of northern Europe. Involvement of male genitourinary system in sarcoidosis is uncommon but may be seen in 0.2% of patients. Epididymides and the testes are most commonly involved, followed by spermatic cord and prostate. Epididymal involvement is bilateral in one-third of the cases and this involvement is commonly asymptomatic. However, pain or the detection of a scrotal mass may be seen in a certain subset of the patients. Epididymal involvement may appear as a solid lesion in the epididymis, and surgery may be needed to rule out malignancy . IsolateSarcoidosis should be considered in patients who have multiple lesions involving the testis and epididymis. Sonographic findings may mimic a primary testis tumor or lymphomatous involvement, and the differential diagnosis may be extremely difficult especially in patients who do not have a history of previously diagnosed sarcoidosis. Elevated serum ACE levels may also act as a supportive finding for correct diagnosis , 32, 33.Sonographically the typical imaging clue is the detection of multiple hypoechoic lesions (with or without involvement of the epididymides) scattered throughout the testes Fig. . HoweverIntratesticular hematomas can be seen in trauma cases and the diagnosis is generally straightforward in these patients. However, incidental diagnosis of testicular tumors after trauma is not rare and has been reported in 10–15% of patients with a history of scrotal trauma . Follow-Testicular hematomas can be seen as single or multiple lesions of variable sizes. Sonographic findings tend to vary depending on the age of the hematoma. Characteristic finding is the detection of an iso-hyperechoic mass in the acute phase and differentiating the hematoma from the healthy parenchyma may be difficult. Unlike neoplastic masses, internal vascularity is not expected in hematomas with color Doppler US . HoweverTemporal variation of the hematoma morphology may be better detected with MRI. While T1 hyperintensity is expected in the subacute period, a low T2 signal due to hemosiderin deposition is expected in the chronic phase. Contrast-enhancement within the hematoma is not expected on postcontrast T1W images Fig.  37, 38], 3837, 3Segmental testicular infarction (STI) is a rare condition. Testicular pain is the most common mode of clinical presentation. It is mostly idiopathic, however, several other disorders such as acute epididymo-orchitis, trauma, vasculitis, and hematologic disorders may be the underlying reason. It is most commonly seen in patients who are between 20 and 40 years of age .On gray-scale US the infarcted area appears more heterogeneously hypoechoic as compared to the background parenchyma. Color Doppler US typically shows absence of vascularity in the infarcted segments. In the early phase they generally appear as a solid lesion; however, the absence of vascularity may favor the diagnosis of STI over a tumor. The infarcted segment is typically wedge-shaped with the vertex pointing towards the testicular mediastinum Fig. . Follow-MRI may be used in patients where differential diagnosis may not be made with US. On T2W images, STIs are typically seen as heterogeneous parenchymal areas with relatively well-defined borders. Hemorrhagic elements may be detected as hyperintense signal areas within the infarcted area on precontrast T1W images. The absence of enhancement within the infarcted area is typical on postcontrast T1W images. Rim enhancement may be detected in the periphery of the infarcted area in the majority of patients , 39.Leydig's cell hyperplasia (LCH) is a rare, benign condition. It is histologically characterized by small, multifocal, and frequently bilateral parenchymal nodules in both testes. On microscopic examination, the hyperplastic Leydig cells are seen infiltrating between the seminiferous tubules. The size of these non-neoplastic nodules ranges from 1 to 6 mm in size , 40. TheOn US, the imaging findings are variable and the parenchymal nodules may appear as hypo- or hyperechoic. Vascularization may be detected within these nodules on Doppler US examination  Fig. 1717.Fig. 1MRI may detect more nodules as compared to US and characterization may be more successful with this modality. On T2W images the nodules are typically hypointense with avid contrast enhancement on postcontrast T1W images .Testicular adrenal rest (TAR) is a rare benign non-neoplastic testicular lesion. They originate from primordial adrenal gland cells that remained within the developing gonad during the fetal life . These pOn US, they are typically seen in both testes as multiple, hypoechoic nodular lesions with sharp rounded margins in the mediastinum testis Fig. . They teAs these lesions may negatively affect spermatogenesis by reducing gonadotropin levels or obstructing the seminiferous tubules, they may over the long term cause infertility in some patients . GlucocoTubular ectasia of rete testis (TERT) is a benign condition caused by the total or incomplete occlusion of the efferent ducts . PatientOn US, TERT is seen as multiple cystic-tubular anechoic structures replacing the mediastinum testis with no obvious mass effect Fig. . VasculaAlthough its location and imaging findings are typical, it is important to differentiate from semisolid testis malignancies containing cystic degeneration areas that may involve rete testis, such as cystadenocarcinoma of the rete testis . CautionCalcification is not an expected finding in TERT. Additionally, the detection of solid component, heterogeneous internal structure and internal vascularity on Doppler US should be alarming for a malignant process over TERT .Cystic dysplasia of the rete testis is a rare and benign congenital entity observed in the pediatric age group. It may present with unilateral painless scrotal swelling and mimic testicular malignancies . It is fLesion location, patient age, sonographic findings, negative tumor markers, and accompanying ipsilateral genitourinary anomalies are important clues for diagnosis. Although the definitive treatment is surgical excision with testis-sparing surgery, “watch and wait” approach is generally recommended .The paratesticular region includes the spermatic cord, epididymis, tunica vaginalis and embryological remnants . While tOn US, it is important to be aware of tumor mimickers in this area to prevent any unnecessary surgical or medical intervention. Conditions such as scrotal hernia, hematocele, epididymitis, and testicular appendage torsion can frequently present with a paratesticular mass. However the differential diagnosis of these conditions with their clinical and radiological features is generally straightforward Fig. . On the Inflammatory pseudotumor (IPT) is a general term that comprises benign and possibly reactive soft tissue lesions of unknown cause. In the literature, IPT is known by many different names such as fibrous pseudotumor, inflammatory myofibroblastic tumor, plasma cell granuloma, and pseudosarcoma. It is more common in young adults with a male preponderance. It can affect many different organ systems such as the lungs, extremities, gastrointestinal and genitourinary systems .Paratesticular IPTs are uncommon lesions and they constitute 6% of all paratesticular lesions . Most ofPatients usually present with a painless scrotal mass and their pre-operative diagnosis can be quite difficult. IPTs may mimic neoplastic lesions both clinically and radiologically. Their echogenicity on ultrasound may vary depending on the cellular component and the amount of fibrosis . PosteriGenitourinary tuberculosis commonly involves epididymis. However, isolated epididymal involvement is a rare and difficult-to-diagnose entity, which is generally observed in the young adult population between the second and fourth decades of life . It is mIn one case in the literature, tuberculomas were defined as well-circumscribed hypoechoic lesions with intralesional calcifications and mild internal vascularity on US Fig.  55]. It. It55]. It is a rare congenital anomaly characterized by the presence of more than two testes. Supernumerary testes are usually located in the scrotum, less commonly in the inguinal canal or in the intraabdominal region. The most common variant is triorchidism, the presence of three testes, and the extra testis is more common on the left-side. Although most of the patients are asymptomatic, some patients may present with scrotal pain or palpable mass .On ultrasound, solid nodular lesions that have similar echogenicity and echotexture to the other testes are observed . On MRI,Additionally, bilobed testicle, also known as incomplete polyorchidism, is a very rare variant with a few cases in the literature. It has been reported that it can present as a solid nodular isoechoic lesion causing testicular contour abnormality on US, and may mimic malignancy .Splenogonadal fusion is a very rare congenital anomaly arising from abnormal connection between primitive spleen and gonad during embryologic period. In the vast majority of cases, it is observed in the left testicle . AccordiSplenogonadal fusion is commonly associated with inguinal hernia and cryptorchidism. Although it is generally detected incidentally, it may present as a palpable testicular mass and clinically mimic malignancy . On US, Female internal genitalia are a common site for neoplastic and inflammatory disease. The clinical history is of critical importance for differential diagnosis and correct diagnosis may sometimes be difficult based on imaging studies alone. A comprehensive summary of clinical and radiological findings of tumor mimickers in the female genital tract can be found in Table Pelvic inflammatory disease (PID) is a common and prevalent infection among the reproductive age female population. Early diagnosis is critical, as there is a risk for tube-related infertility, leading to increased risk of ectopic pregnancy and chronic pelvic pain. Typical imaging features of early acute phase PID are enlarged uterus, hyperemia, parametrial fat stranding, tubal thickening, pelvic free fluid, and enlargement of the ovaries. As the disease progresses, accumulation of pus and necrotic tissue in the endometrial cavity or the fallopian tubes may ensue. The infectious material may extend to the ovaries and the peritoneum via the fallopian tubes. Pyometra, hydro- pyosalpinx, or tubo-ovarian abscess (TOA) may develop in the late phase of the disease .TOAs may appear as a complex cystic mass with thick enhancing walls and may also demonstrate solid mural nodules. With these imaging features epithelial ovarian tumors may be erroneously considered in these patients. The detection of vaginal discharge and elevated serum inflammatory markers are indicative for an inflammatory process. The presence of pelvic fat stranding and thickening of uterosacral ligaments are also other features of a pelvic infection. On MRI, TOAs usually have T1 hypointense fluid content with corresponding T2 hyperintensity. However, high protein content of the pus may cause elevated T1 signal on precontrast images Fig.  59, 60], 6059, 6Pelvic tuberculosis is another entity that should be considered in the differential diagnosis of patients with complex adnexal masses. Tuberculous TOAs appear as multilocular lesions with necrotic components and demonstrate heterogenous enhancement on post contrast images .A. israelii are gram-positive anaerobic bacteria. They reside in the oral cavity, enteric system and the female genital tract. In rare cases, these organisms may cause a suppurative granulomatous process when the integrity of the mucosal barriers is breached.Actinomyces species such as In patients with pelvic actinomycosis, intrauterine device (IUD) is a common risk factor, seen in around 80% of the cases . IUDs evMixed solid and cystic pelvic masses may be seen in the course of the disease. A characteristic finding of pelvic actinomyces infection is the diffuse spreading of the infectious-inflammatory process across the pelvic tissue planes, due to the secretion of proteolytic enzymes that disrupt the tissue planes and boundaries Fig. . The detThis is a very rare chronic inflammatory entity in the female genital tract manifesting with tissue destruction. Although xanthogranulomatous inflammation is generally limited to the endometrial cavity, tubo-ovarian involvement has been reported in rare cases. On imaging, the disease is seen as complex cystic lesions with thick enhancing walls and solid mural nodularity. Differentiation from neoplastic processes may be difficult based on imaging features. Surgery is mostly necessary for both confirmation of the diagnosis and definitive treatment .IPTs may also be seen in the female genital system. The patients present with symptoms such as abdominal pain, fever, and weight loss. It is almost never possible to exclude malignancy in these cases solely based on imaging features as both processes appear as heterogeneous solid-cystic adnexal masses on imaging Fig. . The diaEndometriosis is characterized by the presence of endometrial glands and stroma outside the uterus. These tissues are hormonally responsive and may cause local inflammation, bleeding, and fibrosis. It is a common cause of pelvic pain and infertility in women of reproductive age .Endometriosis may be asymptomatic and the clinical manifestations mostly depend on the anatomic location of the disease. Although it is generally confined to the pelvis, extrapelvic endometriosis may also occur Fig. . The mosEndometriomas may mimic malignancy from clinical and imaging standpoints. In these patients, definitive diagnosis may require histopathological evaluation. Imaging plays a crucial role for differential diagnosis and medical/surgical treatment planning , 69.Morphologically endometriotic foci may range from microscopic implants to large cystic collections on a wide spectrum. The sonographic findings are highly variable and classic appearance is the presence of a homogeneous, hypoechoic cystic mass lesion within the ovary with diffuse low-level internal echoes . Color fEndometriomas may sometimes appear as a completely solid mass with mural and central calcifications . DiffereMRI is the preferred cross-sectional imaging modality for diagnosing endometriomas. On MRI, endometriomas generally appear as a homogeneous lesion with high signal intensity on T1W images and characteristically low signal on T2W images due to the presence of high concentrations of protein and iron , 68, 73.When evaluating endometriosis, pelvis MR imaging protocols should include T1-weighted fat-suppressed sequence as it can be quite useful in both the differential diagnosis and the evaluation of disease extent. By suppressing fat, this sequence can facilitate the differentiation of endometriomas from other T1-hyperintense adnexal lesions such as mature cystic teratomas, as well as increase the lesion conspicuity and improve the detection of smaller-sized endometriomas .solid masses. Uterosacral ligament is the most frequent location of deep endometriosis [Deep endometriosis happens when endometrial glands and stroma infiltrate the peritoneum and pelvic ligaments or adhere to the serosal surface of the bladder or intestinal wall Fig. . They maetriosis .Fig. 29DOn MRI, the foci of deep pelvic endometriosis may appear as T1 hyperintense lesions due to small hemorrhages. On T2W images hyperintense foci may be observed within the solid endometriotic masses due to the dilated ectopic endometrial glands .The differential diagnosis between deep pelvic endometriosis and peritoneal implants from the gastrointestinal tract or ovarian malignancies may be difficult. The high signal intensity on T2W  is more suggestive for an implant over endometriosis. The presence of other ancillary features such as ascites and a primary tumor focus may also be helpful for diagnosing peritoneal malignant implants , 73, 75.Ovarian torsion is among the well-known causes of acute abdominal pain. Twisting of the ovarian pedicle causing parenchymal ischemia is the underlying pathophysiological abnormality. The great majority of patients with ovarian torsion have an underlying mass which is 5 cm or larger in size –78. TherAcute presentation is the most common form. However, the clinical course may be prolonged in the late presentation and differential diagnosis may be difficult in these patients. This clinical course is typically seen in patients with intermittent ovarian torsion which may cause delayed diagnosis , 84. In Intrauterine ovarian torsion may present as a complex heterogeneous cystic mass in the neonatal period and may cause a diagnostic confusion by mimicking neoplastic lesions such as teratomas. On US, fluid-debris level, internal septations, retracting clot, calcifications and solid areas may all be seen Fig. . DopplerEctopic pregnancy (EP) is a condition characterized by the implantation of a fertilized ovum outside the endometrial cavity. The most common locations are fallopian tubes (95%) and ovaries (3%) . Among tThe presence of missed menstrual period with elevated serum beta-hCG levels is typical for diagnosis. However, in case of chronic EP, a rare type of EP, history and beta-hCG values may not be reliable. Since the number of chorionic villi is much less in chronic ectopic pregnancy, an increase in serum beta-hCG values may not be detected . MoreoveTransabdominal and transvaginal US is very useful for evaluation and patient follow-up of EP. However, MRI is now being increasingly used as an advanced examination method due to its high soft-tissue resolution and lack of ionizing radiation . In the When EP develops in atypical locations such as the cervix, it is much more difficult to consider EP in differential diagnosis and it may cause diagnostic confusion . HoweverAdnexal masses detected during pregnancy are generally benign in nature and can be monitored conservatively with detailed clinical and radiological evaluations. The frequency of malignant lesions has been reported as less than 1% . DeciduaDecidual changes expected in the endometrium during pregnancy may also rarely be seen in ovarian endometriomas and can mimic malignancy . Being aOn US, DOEs are seen as complex adnexal cysts containing a solid component. Marked vascularity within the solid component is a typical finding on Doppler US . Since sOn the other hand, presence of a solid component within endometrioma should be accepted as an alarming finding in terms of malignancy, even in case of pregnancy. Therefore, even if the DOE is considered primarily, follow-up imaging should be recommended. In DOEs, significant increase in size is not expected on serial imaging . SimilarHL is a benign condition characterized by enlarged ovaries and multiple ovarian cysts. Unilateral involvement is very unusual, and bilateral involvement is seen mostly. It is usually seen in the presence of multiple pregnancy or GTN, as it is associated with high beta-hCG levels. Rarely, HL may be seen in singleton pregnancies with normal levels of beta-hCG. Spontaneous regression during pregnancy is not expected, but it shows involution when pregnancy ends or when the underlying GTN is treated , 97.PL is a rare non-neoplastic entity resulting from the excessive proliferation of luteinized stromal cells secondary to increased beta-hCG levels during pregnancy, and disappears in the postpartum period. Most of the patients are asymptomatic, and it can be detected incidentally. In 25% of the patients, endocrinological findings such as maternal or fetal virilization may be observed. While multiple lesions were reported in half of the cases, bilateral involvement was observed in one-third of the cases. They can present as solid or heterogeneous cystic lesions on imaging, and if not recognized correctly, they may result in unnecessary oophorectomy. Follow-up is recommended as their size regresses progressively, and they are generally expected to disappear within 3 months after delivery , 98.RPOC can be defined as the placental tissue remaining in the intrauterine cavity after pregnancy ends. It usually presents with postpartum hemorrhage and may be confused with GTNs due to high beta-hCG level in the early period. In particular, when RPOC coexists with placental implantation anomalies such as placenta accreta, it may be falsely interpreted as an invasive neoplastic mass . During On ultrasound, RPOC is seen as heterogeneous material within the endometrial cavity, thickened endometrial echo complex, or an intrauterine mass . CalcifiGenital organs are commonly affected by neoplastic and non-neoplastic diseases in both sexes. The clinical signs and symptoms are mostly non-specific and imaging is necessary for differential diagnosis. Systemic findings, clinical history, patient demographics and close communication with the referring physician are key factors, in addition to imaging findings, for accurate diagnosis. Despite all efforts, histopathological confirmation may be needed for definitive diagnosis.


Intra-ampullary papillary tubular neoplasms (IAPNs) are relatively rare kind of neoplasms occurring in the region of the papilla which exhibit significant malignant transformation. The patient was concerned about his pain and the possibility of malignancy.We report a case of a 47-year-old male who presented with persistent upper abdomen pain. Following detail investigations, he was diagnosed as IAPN and managed by transduonal ampullectomy (TDA).The insidious onset of IAPN along with its high risk of malignancy makes it mandatory for its proper treatment. Although, endoscopic approach is advantageous for initial therapy, it has some technical difficulties. Hence TDA forms the cornerstone in the management of IAPN with good prognosis.Transduodenal ampullectomy is a safe and feasible option for IAPN. It can be the first choice of treatment in selected cases where endoscopic papillectomy is not available. •Intra-ampullary papillary tubular neoplasms (IAPNs) are unusual neoplasms capable of potential malignant progression.•We report a rare case of IAPN which was treated through transduonal ampullectomy (TDA).•TDA can be adopted as an alternative treatment approach to manage IAPNs with great efficacy and fair long-term results. It was not associated with fever, vomiting, abdominal distension, jaundice, melena, loss of appetite or weight loss. There was no history of patient receiving any medication in the past. There was no any significant family history.For these complains the patient underwent upper gastrointestinal (UGI) endoscopy which showed bulky ampulla with growth arising from the ampulla of vater . EndoscoAll hematological and biochemical findings were normal except total bilirubin, 4 mg/dL ; direct bilirubin, 1.0 mg/dL  and alkaline phosphatase,262 IU/L . The tumor markers assessed were cancer antigen 19.9(CA 19.9), 16.6 U/mL  and carcinoembryonic antigen (CEA), 1.69 U/mL .He was planned for TDA. The procedure was done by a senior consultant HPB surgeon. Upper midline incision was given and exploration of the abdominal cavity and the liver was done. The duodenum and pancreatic head were mobilized from the retroperitoneum by a Kocher maneuver. Palpation of the pancreatic head was done to exclude an underlying pancreatic head tumor. A longitudinal duodenotomy, the ampulla of Vater was identified. Cannulation of the ampulla was done. Local excision of the ampulla was performed by electro-cautery with careful identification of the pancreatic and bile ducts. Both ducts were cannulated to prepare for reconstruction, a separate opening of the pancreatic and bile ducts was created by single 5–0 suture (duct-to-mucosa) and two-layer closure of the duodenal wall completed reconstruction.Intraoperative findings; liver and peritoneum were normal. There was no ascites. There was a mass of size 3 × 1.5 cm in ampulla , Fig. 5.HPE reports showed polypoidal tumor composed of closely packed tubular glands lined by pseudostratified columnar epithelium with loss of polarity and moderate nuclear atypia suggestive of IAPN of high grade and stalk was free of tumor . His pos3Intra-ampullary papillary tubular neoplasms (IAPNs) are rare neoplasms characterized by exophytic growth, variable cellular lineage, and a spectrum of dysplasia. More than 80% of the cases show a mixture of low and high-grade dysplastic foci within the same lesion. IAPNs constitute 33% of primary ampullary tumors and 5.5% pancreaticoduodenectomy/ampullectomies with neoplasms Clinical presentation of patients with IAPNs is unspecific and mostly related to obstruction of the common bile duct or pancreatic duct. Typical symptoms are abdominal pain, jaundice, weight loss, diarrhea, diabetes, nausea and vomiting. Age peak is from the sixth to seventh decade In most cases of IAPN without infiltration or metastases, surgical resection is recommended [11]p = 0.145), and the resection margins were negative in both groups. This study suggests that TDA is as safe as EP for treating benign periampullary tumors Kim et al. had studied 31 patients with ampulla of Vater tumors retrospectively. He investigated the safety and availability of TDA and endoscopic papillectomy (EP) were compared. There was no significant difference in the occurrence of complications between the TDA group and EP group , Sumita Pradhan (SP) and Romi Dahal (RD) = Study concept, Data collection, and surgical therapy for the patient.Susan Pradhan (SP*), Romi Dahal (RD) and Krishna Mohan Adhikari(KMA) = Writing - original draft preparation.SP*, RD and KMA = Editing and writing.RSB and SP = Senior author and manuscript reviewer.All the authors read and approved the final manuscript.Not applicable.Professor Ramesh Singh Bhandari. Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Institute of Kathmandu, Nepal, Phone: +977-9841270203 P.O. Box: 1522.Not commissioned, externally peer-reviewed.None.


Cerebral amyloid angiopathy related inflammation (CAA-ri) is a rare encephalopathy resulting from perivascular inflammation after β-βamyloid (A) deposition in cerebral vessels leading to progressive dementia, focal neurological signs, seizures and intracerebral hemorrhages. This condition is characterized on magnetic resonance imaging (MRI) by patchy or confluent T2/fluid attenuation inversion recovery (FLAIR) hyperintensities in the cortex and subcortical white matter located mainly in the same areas of pre-existing multiple microhemorrhages. In this report of 2 cases of “probable” CAA-ri women aged 71 and 68, we propose a review on the pathophysiological, clinical, radiological, therapeutic and prognostic aspects of this little-known and poor outcome condition.Even though an apparently favorable initial evolution after steroid and/or immunosuppressive treatment, CAA-ri course is unpredictable and often associated with low survival rates. We suggest the importance of timely and proper clinico-radiological evaluation in suspected CAA-ri cases, in order to start an appropriate treatment even without the brain biopsy. Cerebral amyloid angiopathy related inflammation (CAA-ri) represents an unusual and life- threatening manifestation of Cerebral amyloid angiopathy (CAA), a frequent age-related encephalopathy, with an unfavorable outcome in the majority of the patients. It is subsequent to β amyloid storage in the media and adventitia of the small and medium sized arteries and capillaries of the cerebral cortex and the leptomeninges Radiological findings and clinical data play a key role in the diagnosis of this rare condition according to Chung criteria Despite an apparently favorable initial evolution after a prompt empirical immunosuppressive therapy We report two cases of probable CAA-ri supported by clinical and radiological evidences and their serious complications.A 71 years old woman presented to our hospital with dysarthria and impaired ambulation with a clinical history of progressive worsening of left hemibody myoclonus, facial nerve dysfunction, and mild diffuse hypertonia.The patient has made some admissions in other hospitals with a progressive worsening of clinical and behavioral symptoms becoming noncompliant, in soporous state, hostile, and disoriented.On admission laboratory tests disclosed hypogammaglobulinemia and severe lymphocytopenia.Electroencephalogram (EEG) was normal. Hyperactive responses using deep tendon reflexes tests (DTR) was observed.The patient was treated with bolus administration of steroids and with cyclophosphamide and azathioprine.A brain MRI study revealed cortical-subcortical abnormal hyperintensities areas on FLAIR images in both cerebral hemispheres. SWI imaging demonstrated several punctate hypointensities, referred to cortical ferromagnetic storages, in particular hemosiderin within the above areas not sparing the subcortical U-fibers.After the intravenous administration of Gadolinium, all of the mentioned lesions showed gyral enhancement on post-contrast T1 W images Fig. 1CASThereafter, the patient was transferred to hospice care with oral prednisone treatment until the exitus occurred few weeks later.A 68 years old woman was admitted in our hospital due to the sudden onset of paresthesia and spastic paraparesis of the left leg and sphincters’ dysfunction and with a history of tension headache, confusion, nausea and vomiting. She presented positive left Babinski sign, hyperactive responses of deep tendon reflexes, normal cognitive function and cranial nerves. Routine laboratory tests, serological tests  and CSF were unremarkable except for positive ANA (antinuclear antibody).She underwent contrast-enhanced magnetic resonance imaging (MRI) of the brain and spine, which revealed a little cluster of cortical-subcortical and peripherical hypointense foci on Susceptibility weighted imaging (SWI) sited in the right superior temporal gyrus and near the angular gyrus, probably due to micro-hemorrhages , without abnormal signal of the surrounding white matter on T2W and FLAIR images. During hospitalization she was administered bolus steroids .Fig. 2CASeven months later a follow up brain MRI disclosed a severe spreading of punctate microbleeds on SWI in cortical and cortical-subcortical areas of both hemispheres, in the brainstem and in the cerebellum. Some of CMBs tended to cluster, leading to macrohemorrhages, in both temporo-parietal region, superior frontal gyri, and cingulate gyri and in the right inferior cerebellar hemisphere.Additionally, a blurred WM hyperintensity on long TR sequences was observed only in the left bulbar pyramid where a serpiginous hypointensity on SWI was detected .Fig. 3 identifies a heterogeneous group of disorders caused by deposition of an β amyloidogenic protein in cortical, leptomeningeal and cerebellar vessels and rarely in the brainstem or basal ganglia The toxic effect of Aβ deposits activates a cascade of biochemical process leading to disruption of the cerebrovascular architecture promoting intracerebral micro and macro-hemorrhages (ICH), which are often associated to CAA-I Typical radiological findings on MRI are asymmetrical reversible long TR sequences hyperintensities of the white matter associated to multiple lobar microbleeds, with or without leptomeningeal or parenchymal gadolinium enhancement. White matter lesions, probably due to vasogenic edema, generally figures as reversible asymmetrical patchy or confluent hyperintense areas on long TR sequences, sited in the subcortical white matter and less frequently the contiguous gray matter. Furthermore, slight leptomeningeal enhancement after contrast administration may be present or not All of the mentioned above radiological signs contribute to identify the “definite” or “probable” CAA-ri based on the Chung's analysis of 72 patients with CAA-ri  8,9]. I,9. I8,9]Unfortunately, brain biopsies were not performed. Even if the histopathological examination is required for a definite diagnosis, the Chung criteria represent an essential tool for early recognition of this disorder, avoiding unnecessary invasive procedures According to the highly predictive of CAA-ri imaging features, the immunosuppressive treatment was started in our patients, with high-dose parenteral corticosteroids followed by oral corticoids, associated with Cyclophosphamide or Azathioprine. As already reported in the literature Despite the lack of histopathological confirmation, our paper confirmed the previous investigations about CAA-ri, evidencing that this inflammatory condition has often a poor prognosis with multiple relapses and autoimmune, pulmonary and thrombotic complications too. Due to the progressive clinical worsening and the controversial therapeutic management, is fundamental a timely and proper clinico-radiological evaluation in suspected CAA-ri cases. Additionally, research is also needed to determine the role of CSF-Aβ autoantibodies. As biomarkers, they could support diagnosis of ARIA and CAA-ri and contribute to a better risk assessment of steroid and/or immunosuppressant administration in these two interrelated and maybe overlapped conditions.Ethical approval was obtained from our institutional ethics committee.The author(s) received no financial support for the research, authorship and/or publication of this article.Written informed consent was retrospectively obtained from a legally authorized representative for anonymized patient information to be published in this article.The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.


Paraganglioma is a very rare extraadrenal nonepithelial tumor. The number of cases of laparoscopic surgery in Paraganglioma is small and controversial. This study encountered a case of successful transperitoneal laparoscopic surgery for a 56‐mm paraganglioma in a 53‐year‐old female. Moreover, previous reports on laparoscopic surgery for paraganglioma are reviewed. A round tumor with capsule with a clear boundary was observed, and no necrosis existed on the cut surface. Moreover, yellow consolidation was observed. The number of cases of laparoscopic surgery in paraganglioma is small and controversial. We experienced a successful case of transperitoneal laparoscopic surgery for 56 mm paraganglioma. In addition, previous reports of laparoscopic surgery for paraganglioma have been reviewed.Paraganglia are groups of neuroendocrine tissues of neural crest origin closely related to the autonomous nervous system. A tumor derived from the paraganglia is a paraganglioma (PGL), which is an extraadrenal nonepithelial tumor.2A 53‐year‐old woman was diagnosed with an ultrasound image of her abdominal mass during a health examination. The patient was then referred to the hospital for a close examination of this abdominal mass. No past medical history and family history. Blood test findings: Hemoglobin, 14.0 g/dL; Carcinoembryonic antigen, 3.0 ng/mL; Carbohydrate antigen 19‐9, 6.7 U/mL; and Soluble interleukin‐2 receptor, 205 U/mL.Abdominal ultrasonography showed a 56 × 43 mm hypoechoic tumor with smooth edges, internal heterogeneity, and no blood flow signals observed in the gastric corpus and posterior wall of the tail of the pancreas Figure . Abdomin2.1Based on the aforementioned findings, gastrointestinal stromal tumor (GIST) of the stomach, Schwannoma, and leiomyoma were listed as differential diagnoses. GIST of the stomach was most suspected, and the treatment modality was decided to be surgery.Surgery was started in the lateral recumbent position with a transabdominal approach. Ports were inserted to form a reverse trapezoid with the umbilicus as the center. The tumor was separated from the gastric wall after the omental bursa was opened. The tumor was at a location surrounded by the left margin of the aorta, the upper margin of the renal artery, and the upper margin of the pancreas and the splenic hilum. The exfoliation of the retroperitoneum and the tumor was difficult. Thus, the pancreas was tunneled and lifted to achieve this Figure . FeedingThe macroscopic finding was a round tumor with a capsule with a clear boundary, and there was no necrosis on the cut surface. Moreover, yellow consolidation was observed Figure . HistopaThe postoperative course showed high levels of drain amylase and pancreatitis on the 3rd postoperative day. The patient improved with fasting and was discharged 12 days after surgery.3PGLs are currently clinically and biologically divided into two groups, based on the parasympathetic and the sympathetic nervous system involvement, according to the World Health Organization classification. PGLs arising from the parasympathetic ganglia mainly affect the head and neck. Thus, PGLs are described as two subgroups based on location, namely head and neck PGL and sympathetic PGL.Sympathetic PGLs, originating from the chest and abdominal sympathetic nerves, account for 80% of all PGLs.PGL is usually characterized by catecholamine‐related symptoms, such as persistent/paroxysmal hypertension, diaphoresis, palpitation, headache, and anxiety neurosis.Biochemical tests confirm the excessive secretion of catecholamine or metanephrine.The history rather than symptoms, such as high blood pressure and headaches, were considered to be nonfunctional.123I‐meta‐iodobenzylguanidine is a high‐sensitivity test and it is useful for adrenal tumors or metastases.In the imaging studies performed in the current case, contrast‐enhanced CT revealed consolidation with a contrast effect. Moreover, in MRI tests, T1‐ and T2‐weighted images showed low and high signals, respectively. RET, VHL, SDHA, SDHB, SDHC, SDHD, SDHAF2, and MAX are related to PGL.Further, patients with PGL are also recommended to undergo genetic screening to detect genetic mutations that cause the disease. As many as 20 susceptibility genes have been currently discovered for PGL and pheochromocytoma. Germline mutations such as those in Proper preoperative management becomes necessary if excessive secretion of catecholamine is confirmed before surgery. Preoperative preparation by administering α‐adrenergic blockers, β‐adrenergic blockers, or calcium channel blockers and communication between the anesthesiologist‐surgeon team during surgery is important.The standard treatment for PGL is surgical resection. A PubMed search for reports on laparoscopic surgery for abdominal PGL with paraganglioma/laparoscopic revealed 12 case reports, including this case, in a 10‐year period from 2010 to 2020 . Cytological characteristics include granular cytoplasm, prominent nucleoli, vesicular nuclei, pseudoinclusions inside nuclei, and so on. There may be secondary changes like hemorrhage, hemosiderin deposition, sclerosis, and pigmentation of the lipofuscin or melani.In terms of histological features, sympathetic PGLs and pheochromocytomas consisting of polygonal cells, called Immunohistochemistry could confirm the pathological diagnosis and assist in making a differential diagnosis with other microscopically similar tumors. CgA is the most specific feature and helps distinguish PGLs from other neuroendocrine tumors. PGLs are usually positive for Syn, which is less specific than CgA because diffused positive Syn staining is also observed in adrenal cortical carcinomas.In addition, Pheochromocytoma of the Adrenal Gland Scaled Score (PASS), proposed by Thompson et al in 2002, is an index showing the malignancy potential of malignant pheochromocytomas.In conclusion, a laparoscopic tumorectomy by the transperitoneal approach was performed for a case of PGL. Laparoscopic surgery for PGL is generally not recommended. However, in the present case, it was considered to be completely safely resected after examining previous studies and reported cases. Fully understanding the preoperative diagnosis, tumor size, and location and performing the surgery with the best approach method and surgical position is important.None declared.HY: wrote this paper. TT: performed the autopsy, reviewed the pathological findings, and revised the manuscript. HI reviewed the medical image findings and helped to write the manuscript. MM, EN, and HM helped write the manuscript. All authors read and approved the final manuscript.Declaration of Helsinki; Patient gave their informed consent prior to their inclusion in the study.Patient gave their informed consent prior to their inclusion in the study.


Background: Mesotheliomas are benign masses that can arise from any body parts that contain mesothelium, such as the abdominal, pelvic, pleural, and pericardial cavities. Benign multicystic peritoneal mesothelioma is a cystic tumor that arises from peritoneal mesothelial cells. It is a rare pathological entity, as only fewer than 200 cases have been reported. Benign multicystic peritoneal mesothelioma mainly occurs in women, and it is extremely rare in men. Its diagnosis and management are often challenging.Case presentation: This report demonstrates a case of a 61-year-old man who presented to the outpatient clinic with persistent abdominal discomfort that progressed over the years. He had visited different clinics and was referred to a gastroenterologist because of a misdiagnosis. After an extensive clinical evaluation, we failed to provide a definitive diagnosis; thus, diagnostic laparotomy for possible intra-abdominal malignancy was performed. After successful surgical resection of the lesions, the pathology was found compatible with benign multicystic peritoneal mesothelioma.Conclusion: Given its high recurrence rates and potential malignant transformation, meticulous and detailed surgical excision of the cystic lesions is of utmost importance to avoid repeated surgeries. Long-term follow-up is recommended. BMPMs are usually asymptomatic, but with increased size, they can cause abdominal pain, discomfort, bloating, constipation, incontinence, and anorexia. Differential diagnoses include cystic lymphangioma (cystic hygroma), cystic endosalpingiosis, endometriosis, cystic adenomatoid tumors, and malignant peritoneal mesothelioma. Several treatment methods have been described in the literature demonstrating different clinical and long-term results. The treatment of choice is surgical excision. This report describes the case of a middle-aged man who presented with BMPM as a rare diagnosis.Benign multicystic peritoneal mesothelioma (BMPM) is a rare disease, and it is extremely rare in men that can easily be overlooked by physicians. Neoplasia, chronic inflammation, irritation, and hormonal activity hypotheses have been suggested in the etiology, but the exact etiological factor has not been identified until today.This case report was approved by the institutional ethics committee.A 61-year-old male patient, who does not have a history of chronic disease, had consulted different outpatient clinics several times because of longstanding abdominal pain, discomfort, bloating, and loss of appetite. The patient was confined and given various medications for bloating and abdominal discomfort, which were prescribed by general practitioners but failed to relieve the patient's symptoms. In the history assessment, the patient stated that a mild pain persisted for several years, during which he was not admitted to any clinic. With the increase in the frequency of his symptoms in the last few weeks, he sought treatment from different outpatient clinics. He did not have a history of smoking, alcohol consumption, or previous abdominal surgery. The physical examination yields no remarkable findings, except for mild epigastric tenderness. Hemogram and biochemistry panel were within normal limits. Abdominal computed tomography (CT) detected multiple loculated collection areas in the abdomen, the largest of which was observed in the subdiaphragmatic area at the anterior of the liver, adjacent to hepatic segments 8, 4, and 5, and it was 4.7 × 11 × 10 cm in diameter. The mass did not contain any solid components or pathological contrast enhancement . The resAfter an uneventful follow-up, the patient was discharged on postoperative day 5. Pathological examination of the excised specimen with hematoxylin and eosin demonstrated multiloculated, honeycomb-shaped, regular-walled cystic structures filled with clear or yellow serous fluid . Immunoh Approximately 200 cases have been reported in the medical literature since it was first described by Mennemeyer and Smith in 1979. BMPM is usually seen in childbearing young women, and it is rarely seen in men. Unfortunately, information about the etiopathogenesis of BMPM is limited; thus, some researchers consider them as neoplastic lesions, while others consider them lesions caused by inflammatory conditions such as the familial Mediterranean fever, peritoneal tuberculosis, and pelvic inflammatory disease. According to the inflammatory theory, chronic irritation after surgery or chronic inflammation suggests that cystic structures are formed following mesothelial cell entrapment and reactive proliferation. Another theory is the hormonal hypothesis that attributes the condition to sex hormone sensitivity because of the higher prevalence of BMPM in childbearing-age women, especially with those who have a history of endometriosis. BMPMs are usually asymptomatic; when enlarged, they can cause abdominal pain, discomfort, bloating, constipation, incontinence, and anorexia. Diagnosis is usually made by ultrasonography, abdominal CT, and abdominal magnetic resonance imaging. Even though the treatment of choice is surgical excision, there has been an ongoing debate regarding which treatment is more sufficient for BMPMs. While some favor surgery alone like the procedure presented herein, others prefer cytoreductive surgery, followed by hyperthermic intraperitoneal chemotherapy. Image-guided aspiration/sclerotherapy and medical treatment, such as oral contraceptives and gonadotropins are alternative modalities to surgery that can be useful in some cases. BMPM recurrence frequently occurs after treatment and requires repeated surgical interventions. Malignant transformation of BMPM is very rare, and only two cases have been reported to date.BMPM is a rare tumor caused by mesothelial proliferation in the serous surfaces covering the abdomen and pelvis.Herein, we described a case with a rare diagnosis in a patient who had a misdiagnosis and thus went through inappropriate treatments repeatedly for a long period. This case indicates that BMPMs as rare benign tumors, with challenging diagnosis and management. Therefore, elderly patients with persistent abdominal discomfort should be evaluated with imaging modalities such as abdominal ultrasonography or CT for possible intra-abdominal pathologies. Given their high recurrence rates and risk of malignant transformation, we think that the treatment of BMPMs by highly experienced medical centers covers an important dimension.The authors declare no competing interests.This case study was approved by the institutional ethics committee.Written and verbal informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article.


Skeletal muscle metastasis (SMM) from renal cell carcinoma (RCC) has been rarely reported. This case series was performed to increase the clinicians' understanding of its clinical features and treatments.We evaluated the clinical presentations, diagnoses, and treatments of 2 patients with SMM from RCC in our hospital and 39 cases reported in the literature.Among the 41 patients, 4 (9.76%) were women and 37 (90.24%) were all men. The average age was 60.5 ± 12.6 years old (range from 7 to 81). The size of tumors varied from 1 to 28 cm, and the metastatic sites of 6 (14.63%) cases were in the heads, 20 (48.78%) in the limbs, 9 (21.95%) in the trunks, 3 (7.32%) in the buttock, and the other 3 (7.32%) were multiple sites. The mean of intervals between the RCC and the discovery of the first SMM was 73.61 months. More than half of the patients  were diagnosed by MRI and 25 (60.98%) patients performed a biopsy of the mass to establish the diagnosis. Finally, 30 (73.17%) cases performed mass excision. Then the adjuvant therapy was performed in 18 patients including immunotherapy, radiotherapy, chemotherapy, and targeted therapy. The median follow-up after SMM was 9 months , in which the longest survival time of patients with SMM of RCC was 8 years while the shortest was only 3 months.The characteristic clinical feature of SMM from RCC is asymptomatic masses or swelling with a long history which can be preoperative suspiciously diagnosed by MRI. The rapid biopsy of suspected lesions, determination of other metastasis sites, resection of metastasis, and systematic treatment are the recommended treatments of it. Kidney cancer is one of the most common malignant tumors in the urology system, accounting for ~3% of all adult malignant tumors worldwide , and renWe herein describe two cases of skeletal muscle metastasis (SMM) from RCC from 1983 to 2020 in the Peking Union Medical College Hospital and further review the literature regarding SMM from RCC to discuss the clinical manifestations, diagnosis, and treatments of this condition. Because case reports can be an essential source of information for the optimum care of patients for rare events, we aim to increase the clinicians' understanding of the optimal methods of diagnosis and treatment in terms of SMM from RCC.Two patients were diagnosed with SMM from RCC between January 1983 and December 2020 at Peking Union Medical College Hospital. We also identified 39 cases with sufficient medical history information reported in the English language literature from 1979 to 2020; these case reports were retrieved from PubMed and GeenMedical.Age and sex of the 41 patients; site and size of SMM; symptoms and intervals; diagnostic methods; whether a biopsy was done; therapies, postoperative treatments, and follow-up were documented and retrospectively analyzed. The medical services performed for the two patients treated in our hospital were recorded in detail.Case 1 was a 44-year-old Chinese woman who was presented to our hospital with a painless mass on her right leg in September 2011. On physical examination, the mass was about 4 cm in diameter with minor mobility. The patient underwent left radical nephrectomy due to renal clear cell carcinoma (T1N0M0) in 2003. Ultrasonography of the right leg showed a hypoechoic mass measuring 3.0 × 1.8 × 2.1 cm in the skeletal muscle. Further MRI revealed a heterogeneous signal mass, 4.0 × 2.5 cm in size, which is located in the vastus lateralis muscle and showed as slightly high-signal intensity on T1-weight image and high-signal intensity on T2 . Chest aCase 2 was a 63-year-old man who was admitted to our hospital on July 15, 2014, with a 9-month history of a mass in the right iliac accompanied by local swelling and raised skin temperature. Physical examination on arrival at our hospital revealed a mass about 13 × 11 cm in size in the lateral area of the right iliac pterion, which was soft, inactive, and painless. The US revealed that low echo and abundant blood flow signals can be seen in the subcutaneous tissue layer of the right hip. MRI showed that an oval mixed signal about 13.3 × 11.1 × 14.6 cm could be seen from the right psoas to gluteus maximus, involving the right iliac bone . The PETWe identified 39 cases of SMM from RCC reported in English language publications; including our two cases (40 and 41), there were 41 cases . In thesThe SMM from RCC occurs in <1% of patients and is described only in case reports . The repPatients with SMM from RRC usually have no symptoms in the early stage, so the metastases are usually found only when they turn to larger sizes and cause symptoms, such as local pain, swelling, or obvious mass. There is no consensus on the common site of metastasis, but according to our study, limbs seem to be its favorite site (48.78%), which differed from the trunk muscles (83.3%) of the study group in Haygood's report . In our Because of the rarity and unpredictability, diagnosis of malignant SMM is rather challenging. MRI is an important imaging modality to distinguish primary soft tissue tumors from metastatic tumors. Surov et al.  studied Positron emission tomography/computed tomography (PET/CT) and MRI can help understand the morphology of tumors, but the pathology remains the gold standard for diagnosis. Therefore, for SMM suspected from RCC, the biopsy is still necessary to diagnose and differentiate RCC metastasis from other soft tissue tumors . Biopsy Renal cell carcinoma is aggressive and almost 25% of patients are diagnosed with distant metastasis . The medApart from surgical resection, systemic treatment with targeted therapy, immunotherapy, chemotherapy, or radiotherapy might be applied in patients with metastatic RCC, since it provides potential benefit for long survival . RCC itsThis study indicated that the clinical manifestation of SMM from RCC generally involves a long history of asymptomatic masses or swelling; MRI may be more effective and recommended for its preoperative diagnosis. The recommended managements include rapid biopsy of the suspected lesions, identification of sites of other metastasis, resection of the metastatic masses, and systemic treatment.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.JS and ZZ were responsible for collecting, sorting out data, and writing the article. YX and HL were responsible for collecting data and pathologic pictures. PL and XZ were responsible for putting forward ideas and reviewing articles and were the co-corresponding authors of this article. All authors contributed to the article and approved the submitted version.This work was funded by Beijing Municipal Science and Technology Commission: Research and development of transurethral endoscopic surgical robot prototype No: Z191100007619044.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Acute acalculous cholecystitis (AAC) is associated with a high mortality rate. AAC caused by metastasis to the gallbladder is rare. We report a case of AAC caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer.An 84-year-old male visited our hospital because of epigastric pain. Ultrasonography and computed tomography revealed swelling and thickening of the gallbladder wall, but stones were not observed in the gallbladder. We performed emergency surgery with a diagnosis of acute cholecystitis. Laparoscopy revealed the presence of many nodules around the abdominal cavity including the hepatoduodenal ligament. Inflammation of Calot’s triangle was severe, so we performed subtotal cholecystectomy. We also resected one of the peritoneal nodules. Macroscopically, there were no stones in the gallbladder and histopathological examination revealed acute cholecystitis and existence of adenocarcinoma involving the subserosa of the gallbladder wall and the resected peritoneal nodule. After surgery, esophagogastroduodenoscopy revealed Borrmann type II lesions at the antrum and gastric biopsy showed adenocarcinoma. He was diagnosed with advanced gastric cancer with peritoneal dissemination. His postoperative course was good.The cases of AAC caused by gallbladder metastasis have been little reported in the literature. This case is advanced gastric cancer with peritoneal dissemination and AAC was thought to be caused by peritoneal dissemination from operative and histopathological findings. We successfully treated this rare case of AAC with laparoscopic surgery.Although metastasis to the gallbladder is rare, it is necessary to be aware of this possibility when treating AAC. AAC accHerein, we report a case of AAC caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer. This case report is compliant with the SCARE 2020 guidelines .2An 84-year-old man was transferred to our emergency center because of epigastric pain sustained from the previous day. He had hypertension as an underlying disease and he had no history of surgery. His regular medication was antihypertensive drugs. He was not a smoker and he had no history of alcohol abuse. The physical examination of the abdomen did not reveal any findings. His laboratory results showed elevated white blood cell count of 12,900/μL and a slightly elevated C-reactive protein level of 0.72 mg/dl. There was no elevation of total bilirubin and liver enzymes. Abdominal ultrasonography showed thickening of the gallbladder wall and no gallstones were observed . ContrasLaparoscopy revealed the presence of many nodules almost involving the entire abdominal cavity including the hepatoduodenal ligament a.b. The Gross examination of the resected specimen showed that there were no gallstones in the gallbladder a. HistopPostoperative course was uneventful and he underwent esophagogastroduodenoscopy (EGD) on the third postoperative day. EGD revealed a Borrmann type II lesion on the greater curvature of the gastric antrum  and gast3AAC usually occurs in severely injured, or critically ill patients or those patients who are under surgical stress, and comprises only 2–10% of all cases of acute cholecystitis . If the The standard treatment for AAC is cholecystectomy. If the patient is critically ill or not suited for surgery because of underlying conditions, percutaneous transhepatic gallbladder drainage (PTGBD) is recommended as an alternative to surgery . TreatmeMetastases to the gallbladder are very rare and reported to be present in 5.8% of the patients according to the findings of a large autopsy series ,11. MetaIn the present case, we concluded that AAC was caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer. Operative and pathological findings enabled us in diagnosing the patient with AAC caused by gallbladder metastasis. In addition to that, there were two reasons which supported our conclusion. One is that there were no typical risk factors which caused AAC such as recent surgery, trauma, severe hypovolemia, immunodeficiency, and so on. The another is that the patient had been fine before the onset of AAC.We think that metastasis to the gallbladder and the involvement of hepatoduodenal ligament including Calot’s triangle due to the peritoneal dissemination caused severe inflammation and formation of adhesions in the Calot’s triangle, which, subsequently, resulted in AAC. Although, the wall thickness of the stomach was suspected to be increased according to the CT findings; it was difficult to identify peritoneal dissemination preoperatively using this imaging modality especially for the diagnosis of AAC.Fortunately, we were able to perform surgery urgently for AAC without the preoperative diagnosis and the patient had a good postoperative course. Because AAC is life-threatening disease, it is important to perform suitable treatment; cholecystectomy or PTGBD. If AAC is caused by gallbladder metastasis, cholecystectomy is more suitable because of diagnosis and treatment.AAC caused by peritoneal dissemination of gastric cancer like this case is very rare and preoperative diagnosis is challenging. We think that it is important to bear in mind the possibility of metastasis to the gallbladder as a cause of AAC and we need to perform surgery for diagnosis and treatment.4In conclusion, we experienced a rare case of AAC caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer. Although metastasis to the gallbladder is infrequent, it is necessary to consider its possibility as a cause of AAC.The authors declare that they have no conflicts of interest.The authors declare that they did not receive any specific funding support for this report.No ethical approval was necessary.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.HS described and designed this paper. TO, TA and RS performed operation. TM, TO and RS managed postoperative care. All authors read and approved the final manuscript.Not applicable.Hiroaki Sugita and Toshiyuki Okuda are guarantors.Not commissioned, externally peer-reviewed.


Superficial and cutaneous aspergillosis is a rare fungal disease that is restricted to the outer layers of the skin, nails, and the outer auditory canal, infrequently invading the deeper tissue and viscera, particularly in immunocompromised patients. These mycoses are acquired through two main routes: direct traumatic inoculation or inhalation of airborne fungal spores into paranasal sinuses and lungs. Lesions are classified into three categories: otomycosis, onychomycosis, and cutaneous aspergillosis. Superficial and cutaneous aspergillosis occurs less frequently and therefore remains poorly characterized; it usually involves sites of superficial trauma—namely, at or near intravenous entry catheter site, at the point of traumatic inoculation , at surgery incision, and at the site of contact with occlusive dressings, especially in burn patients. Onychomycosis and otomycosis are more seen in immunocompetent patients, while cutaneous aspergillosis is widely described among the immunocompromised individuals. This paper is a review of related literature.  Aspergillus species are a large group of common saprophytic moulds which are isolated from soil, air, and plant materials. Aspergillus species can cause a group of superficial and cutaneous mycoses: distal lateral subungual onychomycosis, proximal subungual onychomycosis, otomycosis, and cutaneous aspergillosis [gillosis ,2.Aspergillus skin infections are nosocomially acquired, particularly in newborn or immunocompromised patients or following medical procedures such as surgery, catheter insertion, or after occlusive dressings in burn patients [Aspergillus superficial and cutaneous features [Almost all patients ,4,5. On features ,7,8.Lesions are commonly solitary and typically develop on the catheter site of insertion, wound dressing, and sites of trauma. The lesions arise as papules, nodules, or ulcerations, or they can mimic dermatophytosis ,9. The initial step of aspergillosis is colonization of the sites, such as the auditory canal, wounds, injuries, and fragile nails. The origin of infection may be conidia of the fungus from the surrounding air that fell and contaminated a wound ; conidiaAspergillus airborne organisms may be introduced into the body  by an object or following a post-operative procedure; otomycosis may also be considered as a super-infection following a bacterial otitis [l otitis ,12,13,14Aspergillus species are ubiquitous environmental moulds present in air, soil, water, and decaying vegetation [getation ,15,16. Bgetation ,18. Aspergillus species have been reported in newborns, and Aspergillus wound infection is recognized among burn patients treated in hospital [Because catheter insertions and surgeries are typically done in hospital, almost all skin aspergilloses are hospital-acquired infections; moreover, umbilical catheter infection by hospital ,4,6.Malfunctions in healthcare facility systems, improper installation, filter damage, and poor maintenance can facilitate the spread of healthcare–associated airborne infections .Aspergillus species [The outcome of aspergillosis depends more on host factors than on the virulence of the  species ,21,22  . Aspergibreakers ,32,33 anbreakers . Many rebreakers .Otomycosis caused by filamentous fungi is usually seen among communities of fisherman . SwimminAspergillus onychomycosis: the patient used to plant beans and therefore her hands were generally exposed to water for long periods of time. Thus, occupation seems be closely linked to the disease’s development [Various factors have been suggested as predisposing factors for otomycosis, including swimming regularly and living in a humid environment . One of elopment , especiaAspergillus genus. Furthermore, some religious, cultural, or aesthetical practices leave the external ear canal wet  , which mAspergillus conidia can develop and grow on damaged skin. Usually, patients have been exposed to several kind of trauma.Aspergillus flavus otomycosis has been linked to ear self-mutilation [Some traumas are induced by the patient’s habits, such as ear self-cleaning leading to otomycosis. Moreover, self-inducted injuries are already described in schizophrenia, and tilation .Athlete’s foot is induced by regular sport activities, which is well described in literature ,30; evenPrimary cutaneous aspergillosis has been related to agricultural trauma, orthopaedic trauma ,34, or tAspergillus on the skin of a burned patient. Furthermore, burn wounds can be infected by Aspergillus genus [Panke et al.  observedus genus ,43,44.A primary cutaneous aspergillosis may act as a source of fungal dissemination to various organs of the body, including the lungs, the heart, and the central nervous system .Aspergillus fumigatus infection was reported in a patient with a lacerated lower limb after being injured in a factory blast; the cause of septic shock was the existence of the fungi within the wound [Septic shock caused by he wound .Aspergillus [A 31-year-old healthy female presented with multiple axillary and perineal ulcers following incision and drainage of slowly growing nodular lesions over a one-year duration. She admitted to shaving her axillae and pubic region with a safety razor several times during the one-year period. Culture and histology revealed a significant growth of ergillus .Aspergillus infections induced by trauma are summarized in Some of the Aspergillus species.Usually, aspergillosis starts from a lung infection subsequent to inhalation of airborne spores. Moreover, in the immunocompromised patient, hematogenous dissemination and invasion of other organ systems, including skin, often follows primary pulmonary infection. Cutaneous aspergillosis can be considered as a cutaneous manifestation of disseminated infection with the Primary cutaneous aspergillosis was previously described in immunocompromised patients ,50, espeAspergillus glaucus.Shetty et al.  describeSeveral reports have described primary or secondary cutaneous aspergillosis in immunocompromised patients who are not infected with HIV, including burn victims, neonates, cancer patients, solid-organ and bone marrow transplant recipients ,57,58,59Diabetes mellitus and hyperglycaemia from hyper-alimentation are additional risk factors in burn patients . DiabetiAspergillus niger skin infection following bone marrow transplant was also described [A. fumigatus inflammatory nodules of the lower limb were reported after a liver transplant [In a literature review, escribed , as wellescribed ,61. Moreansplant .Aspergillus flavus in leukaemia patients [Furthermore, unique painful, necrotic nodule of the calf muscle, toe paronychia, and catheter site necrosis were induced by patients , and invpatients .Aspergillus infections literature, the proportion of patients with diabetes mellitus tended to be high [Aspergillus nails infections. The latter is an emerging onychomycosis pathogen among diabetics, and the risk of having Aspergillus nail disorders among patients being treated for diabetes increases with the duration of the disease [Aspergillus onychomycosis [On the other hand, diabetes mellitus has not been identified as a risk factor for invasive aspergillosis in the general population. However, in the  be high . Diabete disease . In a stomycosis . Nail daSome additional underlying diseases have been associated with cutaneous aspergillosis; they are summarized in Aspergillus infections, such as exploratory medical procedures, medical treatments, and surgery.Different medical procedures are related to superficial and cutaneous Smith and Wallace reported a cutaneous lesion of a patient under radiation therapy for non-Hodgkin’s lymphoma; the lesion was located under the dressing of a venous catheter, and histopathology revealed numerous branching hyphae within the follicular infundibulum . Total pAspergillus otomycosis include the use of hearing aids with occlusive ear mould that may provoke accumulation of cerumen and epithelial debris in the external auditory canal [Aspergillus infection.Predisposing factors of ry canal . The catMany of the cutaneous aspergillosis infections in the early 1980s and 1990s were related to Hickman catheters ,48. The Aspergillus fumigatus [Greenish lesions in the umbilical region of two preterm twins were described. The catheters were removed, and the culture was positive for umigatus . Centralumigatus .In some cutaneous Aspergillosis, the lesions are generally located at points of contact with gauze or dressings . Smith aBandages may be a source of infection . Burn woAspergillus niger at the place of skin abrasion that had been managed by a cyanoacrylate topical skin adhesive was described [Recently, primary cutaneous aspergillosis with escribed .Aspergillus terreus in a paediatric patient who underwent surgical treatment for an open tibial fracture [In otomycosis, predisposing factors include ear medical instrumentation ,71. Ozerfracture .Aspergillus flavus infection in a non-immunocompromised patient.Anderson et al. reported an ear surgical wound healing that was complicated by Primary cutaneous aspergillosis can occur directly in the surgical wound among liver or renal transplantation patients ,61,66.Fungal infections are a well-known complication of broad-spectrum antibacterial use. Furthermore, otitis may be exacerbated by the prescription of broad-spectrum antibiotics such as fluoroquinolone eardrops .Currently, mixed bacterial and fungal otitis are the consequence of long courses of bacterial otitis treatment, leading to the alteration of the normal ear flora .Corticosteroids significantly impair the functionality of innate immunity, and steroid-induced hyperglycaemia might further weaken the innate immune response against mould infections such as Aspergillosis ,70.Agranulocytosis treated with antithymocyte globulin was related to skin aspergillosis ,51Aspergillus in burn patients [Prolonged hospital stay and the use of broad spectrum antibiotics were related to cutaneous patients , and thepatients .Aspergillus species [Aspergillus niger was seen in chronic unilateral otomycosis and invasive otitis externa [Aspergillus otomycosis is relatively frequent. Mycological study of otomycosis in the eastern part of Maharashtra (India) revealed 25% of Aspergillus cases [Otomycosis is a fungal superficial, subacute or chronic infection of the external auditory canal with some rare invasive complications involving the middle and inner ear. Pruritus is the most common fungal symptom of otomycosis . Rarely, species . In addi externa . Aspergius cases .Aspergillus otomycosis can be seen in immunocompromised hosts, after open-cavity mastoidectomy surgery, after the accumulation of epithelial debris in the external auditory canal, and after the use of hearing aids with an occlusive ear mould [Predisposing factors include living in a humid climate, moisture, bathing, the presence of excessive cerumen, wearing turbans, repeated use of topical antibiotics and steroids or ear oil instillation ,35,36, mar mould . Many faar mould . The othar mould .Aspergillus flavus [Aspergillus niger, Aspergillus fumigatus, Aspergillus versicolor, Aspergillus candidus, and Aspergillus persii [The predominant fungal pathogens in otomycosis are different in various literature reports . They ins flavus   [Aspergillus is considered to be the most prevalent otomycosis agent in India and China [In a study conducted in Egypt, the majority of fungal otitis cases were related to f cases) ; furthernd China ,82.Aspergillus species are described  [In chronic otitis media, different isolates of terreus) ,84. Mostterreus) ,86.Aspergillus is present.Otoscopy may reveal variable black, green, or grey fluffy elements in the ear canal when It is not uncommon for otomycosis to develop in patients following acute bacterial otitis media with otorrhea  or with Aspergillus heads and abundant septate hyphae, in addition to multiple specific fungal structures including microconidia.Since clinical features of otitis are not specific, laboratory diagnosis is essential to define the correct aetiology of otomycosis and to identify effective antifungal therapy, depending on the type of otitis and the fungal pathogen. Certain otomycoses may reveal microscopic images that are highly suggestive of the etiological agent. Microscopy typically shows numerous Onychomycosis, known as tinea unguium, is a chronic fungal infection of the toenails or fingernails that is usually not painful but can affect a patient’s quality of life by interfering with footwear. The toenails are more frequently involved than fingernails. Onychomycosis may affect up to 30% of the population by age 60 and 70.Trichophyton rubrum [Aspergillus species are the second most frequent agents of non-dermatophytic onychomycosis [Aspergillus species is rare , and the mixed cultures of Aspergillus accounted for almost 15,1%. The latter was in combination with fungi such as Penicillium or other non-dermatophytes fungi [In addition, it is speculated that ed nails . A revienization . In Malaes fungi .Aspergillus species, although no risk factors are evident in most of cases [Diabetes, peripheral vascular disease, orthopaedic trauma, and advanced age are the most important underlying conditions in onychomycosis due to of cases .Aspergillus moulds flourish [Numerous non-dermatophyte filamentous fungi are usually isolated as commensals from damaged nails, mostly from the toenails of elderly . The toeflourish .Toenails are more affected by onychomycosis than fingernails, which is probably because of their slow growth and is perhaps encouraged by external factors such as trauma and poor circulation .Aspergillus sp was the most frequent one [Dhib et al. included 7151 patients (4709 women and 2442 men) with clinical suspicion of onychomycosis; moulds accounted for 4.2% of cases, and uent one .Aspergillus sp are chalky white nail, rapid involvement of lamina, and painful perionyxis without pus [Aspergillus flavus involving all fingernails and toenails of an immunocompromised patient [The clinical characteristics suggesting onychomycosis due to hout pus . Kara et patient . In rare patient .To definitely set up a diagnosis of aspergillosis of the nails, one should not depend fully on the clinical signs, which by themselves may be confusing.Aspergillus. Initial cutaneous disease is infrequent and is most commonly caused by Aspergillus fumigatus, Aspergillus flavus, Aspergillus terreus, and Aspergillus ustus.Cutaneous diseases of multiples aetiologies are commonly encountered in human clinical practice; cutaneous aspergillosis is usually a skin presentation of disseminated infection with the genus Primary cutaneous aspergillosis occurs in the sites of direct skin lesion or injury following surgery, burns, trauma, occlusive dressing, or intravenous cannulation ,26. It cSecondary cutaneous aspergillosis spreads through hematogenous dissemination to the skin from a distant point. Usually, it follows the inaugural pulmonary infection ,51,58,72Aspergillus arrives at the skin or mucosa from a neighbouring cavity, for example, paranasal or maxillary sinuses.There is a third route by which A. terreus are particularly rare [Cases of cheek, nose, and eyelid necrotic ulcers following rhinosinusitis have also been reported . Moreoverly rare . Althougrly rare , aplastirly rare ,54,55, crly rare , and agrrly rare ,61,116. Aspergillus tamarii [Aspergillosis affects 0.4–7% of hospitalized patients with burn injuries . Cutaneo tamarii .Aspergillus that can usually colonize skin and upper respiratory tract; therefore, additional risk factors are needed to trigger an Aspergillus infection.However, all superficial and cutaneous lesions cannot be attributed to environmental Aspergillus species are ubiquitous and saprophytic; they can cause a category of superficial and cutaneous mycoses: onychomycosis, otomycosis, and skin aspergillosis. This group of diseases caused by Aspergillus genus is relatively rare and poorly described.Colonization is the initial step in aspergillosis. Fungal conidia can develop and grow on a damaged skin or after inhalation. Risk factors are various and they include: (a) environmental factors, such as climate, outdoor and hospital conditions and (b) host factors, including occupational exposure (agriculture exposure), increased local humidity and skin maceration, trauma exposure , underlying medical conditions , and medical procedures .Aspergillus niger. Mould onychomycosis is dominated by Aspergillus flavus, and cutaneous aspergillosis is caused principally by Aspergillus fumigatus.The main causative agent of otomycosis is Aspergillus growth needs a fragilized keratin . In this clinical group of superficial aspergilloses, immunosuppression can cause more severe and aggressive forms of otomycosis and onychomycosis.Otomycosis and onychomycosis are very common diseases. Due to the incapacity of an effective keratolysis, Aspergillus entity is seen more in immunocompromised patients, especially after catheter insertion or medical procedure; otherwise, trauma and burn can also predispose to cutaneous Aspergillus.On the other hand, the cutaneous The treatment of cutaneous and superficial aspergillosis is based on antifungal drugs . Surgical debridement can be required, especially in the cutaneous, ulcerative, or necrotic forms (burn patients). However, aspergillosis is relatively recurrent and difficult to treat. Thus, patient education regarding predisposing factors is necessary, as highlighted in this paper.


Apatinib is a new oral tyrosine kinase inhibitor that targets vascular endothelial growth factor receptor-2. It has been proven effective in treating multiple solid tumors. Herein, we report the case of a 67-year-old Chinese patient who was diagnosed with recurrent and malignant transformation of intrahepatic biliary cystadenoma. After multidisciplinary team discussion, the team considered that the remaining liver volume was insufficient for surgical resection. The patient refused chemotherapy and radiotherapy and was willing to take apatinib. Initially, the patient experienced severe tongue ulcers and difficulty eating. The dose of apatinib was then adjusted to 250 mg/day. To date, he has been taking apatinib for 48 months. Regular re-examination showed that the tumor had significantly decreased in size. On January 16, 2021, a CT scan revealed a tumor diameter of 4.5 cm. In our case, the patient achieved partial response and progression-free survival(PFS) of 48.0 months. During treatment, the patient’s appetite and mental state were expected. The treatment did not induce hypertension, fatigue, hand-foot syndrome, or liver and kidney damage. Apatinib may be an option for the treatment of advanced intrahepatic biliary cystadenocarcinoma. Its toxicity is controllable and tolerable. The exact curative effect still needs to be evaluated in more cases. Apatinib  is a multi-target, small-molecule tyrosine kinase inhibitor that can selectively inhibit the tyrosine kinase activity of vascular endothelial growth factor receptor-2 (VEGFR-2) and inhibit tumor neovascularization, thus suppressing tumor growth. Clinical observations have shown that apatinib has a specific anti-tumor effect in various tumors –3. HowevOn December 10, 2016, a 67-year-old man was admitted to our hospital to further evaluate a liver mass discovered during routine postoperative examination in a local hospital. The patient had no clinical discomfort. Past History: On December 2, 2011, the patient underwent a left lateral hepatectomy because of abdominal magnetic resonance imaging (MRI) showing a multilocular cystic mass in the left lateral lobe of the liver (Intrahepatic bile duct cystic tumor (IBCT) is a rare hepatic cystic tumor, and its aetiology remains unknown. It accounts for 5% of all intrahepatic cystic diseases . Due to IBCA is a multilocular liver malignant tumor originating from the IBC and is composed of mucous-secreting epithelial cells , 9. PrevThe clinical manifestations of IBCA and IBC are very similar, making diagnosis difficult. If an ultrasound shows that the intracapsular sound transmission is poor, the cyst fluid is thick, the intracapsular septum is thickened, and the mural nodule is larger than 1.0 cm with coarse calcification; cystadenocarcinoma may also be indicated . Choi etSurgical resection is the first choice for treating IBCT because of the difficulty in diagnosing IBCA before surgery and the high malignant transformation rate . The posIBCA is not sensitive to radiotherapy or chemotherapy, and advanced patients lack effective treatment. Radiotherapy and chemotherapy are suitable for patients with advanced tumors, unresectable operations, or late remission of symptoms , 19. In Tumour angiogenesis is a critical step in tumor growth and metastasis. It plays a vital role in providing oxygen, nutrition, and growth factors for tumors; therefore, anti-angiogenesis agents can treat solid tumors . ApatiniIBCA is a rare malignant tumor of the liver. IBCA is not sensitive to radiotherapy and chemotherapy, and patients with advanced IBCA lack effective treatment. We think that apatinib may be a new option for the Treatment of IBCA. Its efficacy and safety need to be confirmed by further study..The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by The Ethics Committee of Affiliated Hospital of Guangdong Medical University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.YY and ML performed the surgery. WC and WM wrote the original draft. CY collected and arranged imaging and pathological data. LL designed the study and revised the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by the National Science Foundation of Guangdong Province (Grant no: 2018A030307076).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A 7-month-old neutered male poodle dog presented with general deterioration and gastrointestinal symptoms after two separate operations: a jejunotomy for small-intestinal foreign body removal and an exploratory laparotomy for diagnosis and treatment of the gastrointestinal symptoms that occurred 1 month after the first surgery. The dog was diagnosed as having small-bowel obstruction (SBO) due to intra-abdominal adhesions and small-bowel fecal material (SBFM) by using abdominal radiography, ultrasonography, computed tomography, and laparotomy. We removed the obstructive adhesive lesion and SBFM through enterotomies and applied an autologous peritoneal graft to the released jejunum to prevent re-adhesion. After the surgical intervention, the dog recovered quickly and was healthy at 1 year after the surgery without gastrointestinal signs. To our knowledge, this study is the first report of a successful treatment of SBO induced by postoperative intra-abdominal adhesions and SBFM after laparotomies in a dog. Postoperative intra-abdominal adhesions (PIAs) are inevitable complications of major abdominal surgery in both humans and animals, with various extents of adhesion formation depending on the patient ,2,3. AmoWith computed tomography (CT), small-bowel fecal material (SBFM) was first described in humans as “small-bowel fecal signs (SBFSs)”; particulate matter was shown to be mixed with gas bubbles in the lumen of dilated small-bowel loops . SBFM waThis case report describes the successful surgical treatment of and preventive measures against SBO induced by two unusual postoperative complications, PIA and SBFM, in a young dog. To the best of our knowledge, this is the first report to describe the treatment and outcome of concurrent PIA and SBFM occurring after laparotomies in a dog.®, Davis and Geck, Danbury, CT, USA) 2 months before referral. One month after the operation, the constant diarrhea, vomiting, and anorexia had not improved with symptomatic treatment, including fluid therapy, antiemetics, and antibiotics. Imaging examinations, including radiography and abdominal ultrasonography, showed no foreign bodies, but showed decreased gastrointestinal motility. As the owner suspected that the dog might have eaten foreign bodies again, the referring veterinarian performed another exploratory laparotomy and reported jejunal adhesions and dilatation without any foreign bodies. After the second laparotomy, the dog’s condition deteriorated rapidly, with persistent gastrointestinal signs, including anorexia, vomiting, and weight loss from 3.9 to 3 kg. The dog did not defecate from that point on.A 7-month-old neutered male poodle dog with a body weight of 3.0 kg was presented with anorexia, weight loss, and no defecation at the Konkuk Veterinary Medical Teaching Hospital. According to the referring veterinarian, the dog had been diagnosed with a small-intestinal foreign body (earmuff), which was removed via jejunotomy with 3-0 polyglyconate , and neutrophilia , with some toxic changes and reactive lymphocytes. A biochemical analysis, gas analysis, and coagulation test revealed no abnormalities except the elevated C-reactive protein (CRP) level . Abdominal radiography revealed loss of serosal detail and small-intestinal dilation, with the ratio between the maximal small-intestine (SI) diameter and the height of the fifth lumbar vertebral body (L5) increasing to 2.24. Abdominal ultrasonography revealed a severe dilation with intraluminal intestinal contents and accumulation of fluid in almost the whole jejunal segment, with its largest diameter being 18 mm, as well as jejunal lymph node enlargement. Markedly reduced gastrointestinal motility was generally shown, but remarkable pathological changes were not identified in other gastrointestinal segments except for the jejunum. No foreign material was identified in any segment. A small amount of peritoneal effusion around the urinary bladder and mild hyperechoic change in the mesentery were thought to be due to the previous operation. To identify the cause of the severe jejunal dilatation and the presence and level of the obstacle, a CT scan  was obtained under general anesthesia. The imaging protocols were 120 kVp, 200 mAs, 512 × 512 matrix, and 0.6 rotation time with a 1.25 mm slice thickness. For a contrasting CT examination after the plain CT scan, iohexol  was manually injected at 600 mg iodine/kg into the cephalic vein. All CT images were transferred to a workstation using a commercially available DICOM imaging analysis software . The abdominal CT scan revealed generalized gastrointestinal dilatation with abrupt narrowing of the jejunal segment and SBFS , and 8% dehydration. The dog’s perfusion parameters were within the normal limits. Hematology revealed normocytic normochromic anemia (packed cell volume (PCV), 28.3%; reference range, 37–55%), leukocytosis ), butorphanol (0.2 mg/kg IV), midazolam (0.1 mg/kg IV), and maropitant (1 mg/kg SC). General anesthesia was induced with propofol (4 mg/kg IV) and maintained with isoflurane in oxygen after endotracheal intubation. After an abdominal midline incision was made, diffuse fibrous adhesions were identified throughout the overall jejunum and between the jejunum and peritoneal wall. Bowel plication was identified between the proximal jejunums, adhering to the serosal layers with loops positioned at acute angles, causing the narrowing of the lumen. The jejunal loop proximal to the narrowed lesion was markedly distended and hyperemic, and the distal jejunum and ileum distal to the narrowed lesion were obstructed with hard intestinal contents that could not be squeezed A. The laThe hardened fecal-like contents were removed via the enterotomies that were made over the distal end of the jejunum and ileum and were identified as hard and dry fecal matter corresponding to a fecal score of 1. The enteronotomy sites were closed with 3-0 polydioxanone (PDS) in a simple interrupted pattern. After securing the intestinal patency and confirming that there was no leakage, the serosal surfaces of the entire small intestine were closely examined, and a remarkable serosal injury of 7 cm in length was identified in the proximal jejunum where the adhesion was separated A. To prePostoperatively, the dog recovered from anesthesia uneventfully. He was quiet, alert, and responsive, and he maintained normal vital signs and normotension. His postoperative medication included continuous infusion of fentanyl (4 μg/kg/h) and lidocaine (50 μg/kg/h) for the first 24 h, followed by carprofen  and tramadol  for 5 days, maropitant (0.1 mL/kg subcutaneous once daily) for 4 days, and misoprostol  for 5 days. As intestinal supplements, probiotics were administered for 2 weeks after the operation. During hospitalization after the surgery, the dog showed no vomiting, regained his appetite, started to defecate  from postoperative day 2, and was discharged on postoperative day 4.Postoperative follow-up examinations, including radiography, ultrasonography, and blood examination, showed no dilatation, obstruction, or plication, with normal motility of the overall intestines. Regenerative anemia, mild hypoalbuminemia, neutrophilic leukocytosis, and elevated CRP levels were identified immediately after surgery, but returned to within the reference ranges in 2 weeks. Throughout the one-year telephone follow-up, the dog remained healthy without any clinical signs associated with gastrointestinal disease. Considering the history of two separate previous operations, the confirmation that there were no other obvious pathological changes, including foreign bodies, and the fact that there was no recurrence after resecting the obstructive jejunum, this patient was tentatively diagnosed with SBO induced by PIA.PIA occurs when the balance between fibrin deposition and fibrinolysis, which proceeds normally in the case of peritoneal injury, is disrupted by specific causes. The peritoneum has powerful coagulation and fibrinolytic capacity, which normally exceeds coagulation; thus, abdominal adhesion does not commonly occur under normal conditions . As the In human medicine, PIAs are the most frequent causes of SBO, of which adhesions account for 50–75% of SBOs, which occur after surgery in 80% of all cases ,15. ThisHuman patients with PIA-induced SBOs usually improve with non-surgical treatment, and 80–100% of patients experience alleviation of their clinical signs within 2 weeks of the symptoms’ onset after non-surgical treatment ,21. On tFurthermore, SBFSs were identified in the CT results of the dog, and hardened fecal materials in the distal jejunum and ileum were confirmed during surgery. This was first described in human beings in 1995 . In humaThe clinical significance of SBFSs in human medicine remains unclear. Although the relevance of correlation between SBFSs and diagnosis of SBO remains controversial in patients with acute abdominal pain, it has been reported that SBFSs are useful signs for localization of transition zones in SBO patients on account of their tendency to be most prominent in the transition region from the dilated intestinal loop to the collapsed bowel . SBFSs dPIA-induced SBO has been considered as a high-risk recurring problem after surgical correction in human studies (B), which reported overall recurrence rates ranging from 8.7% to 53% ,28,29,30This study describes the first reported case of PIA and obstructive SBFM-induced SBO in a young dog. These two rarely occurring postoperative complications were diagnosed on the basis of the dog’s history and CT results and were successfully treated with meticulous surgical techniques for resection of the obstructive adhesive lesion and removal of the obstructive SBFM via enterotomies. The deperitonealized lesion of the released jejunum was completely covered with autologous peritoneal graft to prevent re-adhesion.