Lipoma is a common benign tumor derived from adipose tissue, with an incidence of nearly 10%. It is the most common mesenchymal tumor throughout the body. However, the pathogenesis of lipoma is not clear yet, and the increased incidence is attributable to obesity, elevated serum cholesterol, diabetes, trauma, radiation, familial predisposition, and chromosome. Primary omental tumor is a rare lipoma occurring in the greater omentum, most of which is reported in the form of clinical case reports. Nevertheless, primary omental tumor is even rarer in children. To date, there have been few reports of clinical cases.We report a rare case of primary omental lipoma in a 6-year-old boy. After an accidental fall, a CT scan found that he had a tumor in the left upper abdomen. He had no history of abdominal pain, abdominal mass, vomiting, etc. The boy was admitted to the hospital within 3 days, and was diagnosed with an intra-abdominal tumor. After admission, abdominal ultrasound and enhanced CT showed a 71 ×40 ×60 mm mass in the left middle abdomen, which was considered a lipoma. There was no abnormality in tumor markers. Through laparoscopic surgery, intraoperative exploration revealed that the tumor was located in the left mid-upper abdomen, and was yellow, solid, soft, and isolated. The intraoperative diagnosis was an omental lipoma. We used an ultrasonic knife to resect the omentum close to the base of the tumor. The tumor was completely resected, put in a retrieval bag and sealed. Finally, the left and right sides of the umbilical incision were extended to take out the tumor tissue. The child received liquid food 6 h after the operation and was discharged 3 days later. The postoperative pathological diagnosis was an omental lipoma. He was seen at follow-up 3 months after discharge and had no complaints, an abnominal ultrasound showed no tumor recurrence.Primary omental lipoma in children is a rare benign tumor of the omentum. Its etiology and pathology are not clear. US, CT, and MRI can facilitate clinical diagnosis and preoperative evaluation. Laparoscopic surgery is an effective treatment, and the prognosis of children is favorable. This case is beneficial to improve the clinical knowledge of pediatric surgeons about this rare disease. Primary omental lipoma is a rare benign tumor of the omentum. The pathogenesis is not clear, and there is no statistical data on its incidence. This lipoma in children is even rarer, most of which are reported in the form of clinical case reports. This study reports the diagnosis and treatment of a 6-year-old boy with primary omental lipoma. Meanwhile, it discusses the clinical characteristics as well as methods of diagnosis and treatment of primary omental lipoma based on previous literature data. This study was approved by the Research and Ethics Committee of our institution, and written informed consent was obtained from the patient's family.A 6-year-old male child was found to have a tumor in the left mid-upper abdomen on a CT examination of his abdomen after an accidental fall. The boy had no history of abdominal pain, abdominal mass, and vomiting. He was admitted to the hospital with an abdominal tumor within 3 days. The initial diagnosis was an intraperitoneal tumor. After admission, laboratory tests showed no abnormality in blood cell count, biochemical analysis, and tumor markers. Abdominal ultrasound and enhanced CT showed a mass in the left middle abdomen, which size was 71 ×40 ×60 mm. Intra-abdominal lipoma should be considered, and the blood-supplying vessels were derived from branches of the omental artery .We performed laparoscopy surgery on the child: three incisions for 5 mm trocars were made on the insufflated abdomen respectively at the left and right sides of the umbilicus and at the anti-Mc Burney's point. Intraoperative laparoscopic exploration revealed a tumor in the left part of middle and upper abdomen, with a size of about 70 ×60 ×50 mm. It was yellow, solid, soft, isolated, and its base was derived from the greater omentum without torsion . PreoperThe operation time was 27 min. The weight of the excised tumor tissue was 295 g, size of about 80 ×55 ×30 mm with; the tumor capsule intact; and the cut surface is grayish-yellow and soft . MicroscPubmed, Springer Link, CNKI, and Wanfang databases were searched before June 2021 to retrieve the related literature of omental lipoma, a total of 12 clinical reports of primary omental lipoma in children were retrieved in the previous literature .Lipoma is a common benign tumor derived from adipose tissue, with an incidence of nearly 10% , 3. The Review-of the retrieved literature of 12 cases of primary omental lipoma in children, found that children with omental lipoma are usually asymptomatic and are discovered incidentally during medical examination, trauma, or abdominal diseases. The main symptoms of these children include abdominal pain, abdominal distention, and abdominal mass. Nausea, weight loss, and intraperitoneal hemorrhage occurred occasionally, and a few children were admitted to the emergency department due to torsion of the omentum. It has been reported that adult patients were hospitalized due to intussusception and intestinal obstruction , 9.P <0.01). In addition, ultrasound-guided percutaneous needle biopsy has been a commonly used method for the diagnosis of intra-abdominal lesions, such as liver, kidney, pancreas lesions, and other solid organs, but it is not commonly used for peritoneal and omental lesions. It may cause controversy by seeding tumor cells along the needle path , Tongji Medical College, Huazhong University of Science and Technology. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.QY and XY designed the study, collected the clinical data, performed the statistical analysis, participated in the operation, and drafted the manuscript. XD participated in the operation and revised the article. All authors read and approved the final manuscript.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.


Adrenal gland myelolipomas are benign, hormonally inactive, and mostly asymptomatic and unilateral tumors. However, it could be symptomatic and bilateral in rare cases. The diagnosis is based on a CT scan and a histological study. We present a rare case of a surgically managed bilateral adrenal gland myelolipoma with a giant mass on the left side in a 40-year-old man who presented in our department for atypical abdominal pain. The patient underwent surgical resection of the left adrenal mass. Due to the resolution of the abdominal pain, a close follow-up for the right mass by CT scan was chosen. Adrenal gland myelolipoma (AML) is a rare, benign, and nonfunctional tumor, firstly described in 1905.A 40-year-old patient, without a particular medical history, was transferred to our urological unit for atypical abdominal pain. Clinical examination found a patient in good general condition, conscious, hemodynamically and respiratory stable, afebrile. Examination of the lumbar fossa found a slight tenderness of the left lumbar fossa. The ganglionic areas are free. The remainder of the physical examination is unremarkable.The computed tomography scan objectified bilateral adrenal masses of fatty density suggesting first myelolipoma measuring on the right 74 mm and on the left 150 mm .Fig. 1CTNo abnormalities in biological assessment, as well as in hormonal investigation for adrenal masses; His serum level of ACTH, corticosteroid, and androgen were within the normal ranges; and his urine Metanephrine/normetanephrine was normal.The patient underwent left adrenalectomy by subcostal incision. With a surgical time of 3 h without complications. The patient remained in the intensive care unit bed the first postoperative day. The patient was declared discharged after four days.The specimen measuring 15.1 cm and weighing 1432 g. Histopathological analysis with hematoxylin and eosin staining revealed a neoplastic proliferation made of mature and variable-sized adipocytes with aggregates of hematopoietic elements, associated with adrenal gland tissue in the peripheral region within the tumor confirming the diagnosis of adrenal gland myelolipoma .Fig. 2A,Due to the resolution of the abdominal pain, the clinical follow-up of the right adrenal myelolipoma was decided. On CT scan, there was no increase in the size of the right adrenal mass after 12 months, The patient remains in follow-up.Adrenal myelolipomas are exceptional, benign, and non-functioning tumors composed of a mixture of mature adipose and hematopoietic cells. Their incidence increase with age, it represents 2% of all adrenal incidentalomas with three times more prevalent on the right side than on the left side because the right adrenal gland is easier to detect during abdominal ultrasonography, but improvements in medical imaging have increased the frequency of detection.,,Usually, adrenal myelolipomas are small, unilateral, and asymptomatic lesions incidentally detected when radiological investigations are done for other pathologies,The etiology of adrenal myelolipoma remains imprecise. There are several hypotheses including and degeneration of epithelial tissues of the adrenal cortex, extramedullary hematopoiesis due to the autonomous proliferation of bone marrow cells transferred during embryogenesis, and the most widely accepted theory is the adrenocortical cell metaplasia of the reticuloendothelial cells due to chronic stimulation such as inflammation, infection, necrosis, or stress.,,The ultrasound of an adrenal myelolipoma typically shows as a well-defined tumor with hyperechoic regions corresponding to adipose tissue and hypoechoic parts of the myeloid component. In 90% of the cases, the diagnosis of AML can be established by using a CT scan which is reported as the most sensitive diagnostic test for AML. It shows a radiolucent, avascular, and well-circumscribed mass that contains variable amounts of soft tissue and macroscopic fat with a negative Hounsfield Unit. Yet, in MRI, the AML appears as high-signal regions in T1 and T2. In contrast with the myeloid component which appears as low-signal in T1 and moderate signal in T2.,,There are no specific guidelines for the management of AML, and the decision should be taken in a multidisciplinary setting on a case-by-case basis. In general, bilateral adrenalectomy should be avoided to conserve hormonal function. Furthermore, Small tumors should be managed by monitoring over 1–2 years with imaging controls. On the other hand, in case of symptoms, significant growth, or hormonal activity, surgical removal is indicated by laparotomy or laparoscopy. Also, large masses of a size bigger than 8 cm should be removed, given their great potential of spontaneous rupture causing a retroperitoneal hemorrhage.We reported an extremely rare case of a bilateral AML with a giant neoplasm in the left side accompanied by abdominal pain in a patient without an endocrine disorder. However, the endocrine function must be preserved when possible. The surgical treatment of the asymptomatic lesions is not obligatory even if they exceed 7 cm, because of the very low risk of rupture, and a close follow-up strategy could be used. The management should be discussed on a case-by-case basis. More case reports and long-term studies are needed to establish clear guidelines for the management of bilateral AML.None of the contributing authors have any conflict of interest, including specific financial interests or relationships and affiliations relevant to the subject matter or materials discussed in the manuscript.


Early detection of immune-related adverse events (irAEs) with immune checkpoint inhibitors (ICIs) is crucial, particularly when these are likely to mimic tumor progression, as well as sarcoid-like reactions. Here, we report the case of a 68-year woman, with a history of four primary cutaneous melanomas (thickest lesion with BRAF mutation removed from the left axilla 2 years before), who was diagnosed with BRAF V600E-mutant metastatic melanoma and treated by ICI targeting the PD-1 receptor. Follow-up whole-body positron emission tomography/computed tomography (PET/CT) using 18F-fluorodeoxyglucose ([18F]-FDG) was performed at 15 months, and FDG-avid subcutaneous nodules on her legs were detected. A biopsy from a lesion on her right leg was obtained, and histology strongly suggested erythema nodosum. Given the isolated nature of these lesions, the normal serum Angiotensin-Converting Enzyme and the context of ICI, an immune-related sarcoid-like reaction was retained as the most likely diagnosis. Recent literature in immune-oncology suggests that erythema nodosum could be directly related to ICI(s). Although erythema nodosum is a rare occurrence with imaging features overlapping with malignancy, it should be considered in the differential diagnosis of suspicious in-transit metastasis, especially when the patient is treated with ICIs and when lesions follow a bilateral distribution. In conclusion, nuclear medicine physicians should keep in mind this irAE when interpreting PET/CT scans in clinical practice in order to avoid false-positive findings.


A paraduodenal hernia (PDH) is a rare type of internal hernia, which results from anomalous rotation and reduction of the midgut loop in the embryo. The diagnosis is often difficult due to nonspecific symptoms. The mortality from an acute internal hernia can be close to 50% when the diagnosis and definitive surgical treatment are delayed. Here we present a rare case of obstructed left paraduodenal hernia (LPDH) in a COVID-positive patient. This is probably the earliest report of acute mechanical intestinal obstruction due to LPDH in a COVID-positive patient. Paraduodenal hernias (PDH) are rare congenital anomalies of the gut resulting from defective rotation and fusion in the embryo leading to the bowel being entrapped within potential spaces or sacs that are lined by peritoneum . They coA 41-year-old male presented to the emergency room with acute onset colicky abdominal pain for two days, associated with absolute constipation. He described having experienced postprandial bloating and abdominal discomfort for one week. The patient was a fisherman and resident from a designated COVID containment zone. He had no history of chronic abdominal pain, previous abdominal surgeries, or comorbidities. No history was suggestive of coronavirus disease 2019 (COVID-19) infection. Abdominal examination revealed tenderness in the umbilical, left hypochondrium, and left iliac regions. Bowel sounds were hypoperistaltic. He was afebrile, with normal vital signs. Blood analysis indicated increased WBC counts (12000/cumm) with leucocytosis. Ultrasonography of the abdomen was inconclusive. The COVID test reverse transcription-polymerase chain reaction (RT-PCR) assay for severe acute respiratory syndrome (SARS)-associated coronavirus was negative. A contrast-enhanced computed tomography (CECT) scan of the abdomen suggested the possibility of LPDH with features of intestinal obstruction and this clinched the diagnosis Figure .During emergency exploratory laparotomy, the majority of the small bowel was found to be herniated into the lesser sac. The sac-like mass contained dilated jejunal and proximal ileal loops alongside the fourth part of the duodenum through an internal opening, namely the paraduodenal fossa of Landzert, near the ligament of Treitz, below the transverse mesocolon Figure .About two feet of the intestinal loops comprising of the jejunum and proximal ileum were meticulously reduced into the peritoneal cavity. Although the intestinal loops appeared dusky initially, the congestion slowly waned off after reduction, and the normal colour with good peristalsis was restored, confirming the viability of the bowel. The rest of the solid and hollow organs appeared normal Figure .On the second postoperative day, the patient developed high-grade fever. His abdomen was soft and he was tolerating oral fluids. Bowel movements were normal. Based on a high index of clinical suspicion, the RT-PCR test was repeated, and it turned out to be positive. The dimer value was 2388 ng/ml by enzyme-linked immunofluorescence assay (ELFA).The patient was shifted to the COVID care unit. The fever lasted for three days and was treated according to the hospital's COVID treatment protocol. The patient made an uncomplicated recovery and was discharged after two weeks when the COVID test result was negative. The patient is on regular follow up for 10 months and is doing well.An LPDH is defined as an abnormal protrusion of the bowel into the Landzert fossa. This fossa is a space that typically gets obliterated around five to ten weeks of embryonic life, when the left mesocolon ascending left colic artery and the inferior mesenteric vein (IMV), fuses with the retroperitoneum. This occurs at the same time when the small bowel is completing the 270-degree anti-clockwise rotation about the superior mesenteric artery (SMA) -5.In about 1% to 2% of the people, it is thought that bowel invagination into the avascular plane posterior to vessels behind the left mesocolon, predisposes to the formation of the fossa. Therefore, the anterior border of this orifice, the IMV, and the left colic artery are shifted or transposed anteriorly, and the left colon mesentery (mesocolon) forms the anterior wall of this hernia.The afferent limb is generally formed by the jejunum close to the fourth portion of the duodenum, and the efferent limb can go as far as the ileum if extensive herniation occurs ,7. AwareThe clinical features are usually nonspecific with a history of chronic intermittent, self-limiting postprandial abdominal pain with an inconclusive clinical workup. Up to 70% of patients give a history of chronicity of abdominal pain. The lifetime risk of strangulation and intestinal infarction is more than 50% .CECT scan of the abdomen can depict pathognomonic findings and can probably be considered the gold standard investigation in PDH. CT appearance of LPDH includes clustering or bunching up of small bowel in the left side of the upper abdomen, into a closed-loop forming a ‘C’ or ‘U’ shaped mass like sacculation with the displacement of the stomach, transverse colon, and the duodenal-jejunal junction . Our patient did not have chronic abdominal pain and he had experienced vague postprandial abdominal symptoms only for one week. Moreover, the patient was initially negative for COVID infection and this was probably due to testing in the initial latent phase of the infection. It is well known by now that coronaviruses commonly cause respiratory and/or enteric infections ,10. In sThe commonly reported gastrointestinal manifestations in COVID patients include acute liver injury and elevated transaminases (66.6%), acute acalculous cholecystitis , acute pOur patient presented with definitive evidence of mechanical intestinal obstruction. It can be speculated that the COVID-19, to be a concomitant infection or the presence of the virus in the gastrointestinal system itself would have predisposed to intestinal distension due to viral enteroneuropathy, resulting in the occurrence of mechanical obstruction in an otherwise asymptomatic patient. Luckily there were no serious gastrointestinal ischaemic complications as the LPDH was diagnosed in time. As stools samples were not studied for SARS-CoV-2 RNA, it is uncertain if the gastrointestinal system was affected by COVID-19. To the best of our knowledge, this is probably the first report of acute intestinal mechanical obstruction due to a PDH in a COVID-positive patient. Our previous experience with PDH probably helped us in surgical management . AdequatInternal hernias are rare causes of acute intestinal obstruction and the diagnosis requires a high index of clinical suspicion. Such rare causes of an acute abdomen should not be overlooked even in COVID-positive patients. CT scan is the diagnostic modality of choice in PDHs. Timely recognition and surgical intervention can improve the outcome.


A fecalith is a common cause of acute appendicitis, and laparoscopic surgery is the mainstay of its management. Literature review shows that a fecalith may be retained in the gut following a laparoscopic appendectomy in some rare cases. In most cases, the fecalith becomes symptomatic with time due to the formation of an abscess, fistulous tract, or inflammation of the appendicular stump (stump appendicitis). We report a case of retained appendicular fecalith presenting with symptoms similar to acute appendicitis, 15 years after laparoscopic appendectomy. A fecalith is a hard stony mass of feces in the intestinal tract. Fecal impaction occurs when a large amount of fecal matter gets compacted and cannot get evacuated spontaneously . In its It can occur in any part of the intestine . Most ofHere we present a case of a retained appendicular fecalith in a patient who presented with an acute abdomen.A 33-year-old male, otherwise healthy, presented to the emergency room with right iliac fossa pain. It was sudden in onset and lasted for about 15 minutes. The pain was severe in intensity and associated with nausea. There was no associated fever, vomiting, or constipation.The patient had a history of an uneventful appendectomy 15 years back for acute appendicitis. He remained asymptomatic for several years following the procedure. However, four years ago, he presented with ureteric colic, and a CT scan abdomen confirmed a left ureteric stone. The CT scan also incidentally demonstrated a fecalith in the right iliac fossa. He subsequently underwent DJ stenting at that time with complete resolution of symptoms.During the current visit, abdominal examination showed tenderness in the right iliac fossa with guarding but no abdominal distention, rebound tenderness, or rigidity. A small mass was also palpable in the right lower abdomen. The patient was otherwise vitally stable. Lab workup showed a total leukocyte count of 10,770/µL and C-reactive peptide levels of 62.7 mg/L. CT scan performed in the emergency room revealed a fecalith in the appendicular stump measuring approximately 17 mm in the maximum transverse diameter (Figure The gastroenterology team was taken on board. Colonoscopy was advised to delineate the exact location of the fecalith and to determine whether it was safe to remove the stone endoscopically. Colonoscopy showed a large impacted and deeply embedded stone in the appendicular stump, covered by normal colonic mucosa and projecting into the cecum Figure .The ileocecal valve was normal in appearance, and deep terminal ileal intubation showed normal small bowel mucosa. It was not considered safe to remove the stone endoscopically due to the high risk of cecal perforation. As a result, the patient was referred for surgical removal of the fecalith. The patient underwent laparoscopic surgery with excision of the appendicular stump containing the fecalith Figure . The proThe risk of developing appendicitis during one’s lifetime is around 7%. A fecalith can be found in roughly one-third of the patients that present with symptoms suggestive of appendicitis .Laparoscopic appendectomy is currently the preferred surgical approach for acute appendicitis. A known but a rare complication of laparoscopic appendectomy is a retained fecalith that can occur secondary to rupture of the appendix before surgery or due to failure to remove the fecalith during surgery . A retained appendicolith can manifest itself in a multitude of ways. Common presentations include intra-abdominal abscesses, delayed wound healing, fistula formation, appendicular torsion, and stump appendicitis ,6.Surgical resection is the mainstay of treatment in the case of symptomatic fecalith or development of its complications .Due to the high risk of infection and potential for stump appendicitis and eventual abscess formation, every effort should be made to remove the appendicoliths at the index operation . AttentiThe lengthiest interval we could find in the literature that reports abscess formation due to a retained fecalith was nine years after appendectomy . UsuallyKeeping the current literature in view, our case seems to be peculiar. Our patient presented with symptoms attributable to fecalith 15 years following an appendectomy. It is interesting to note that the fecalith remained silent over a considerable number of years. We are not sure of the reason for the patient’s current symptoms as there was no evidence of inflammation of the appendicular stump or any pus collection on radiological imaging. However, due to the intensity of the pain, right iliac fossa tenderness, and raised inflammatory marker, some degree of inflammation was considered likely, and it was decided that we remove the fecalith. There is also a possibility that the episode of acute pain was due to mechanical distension of the stump. We attempted to retrieve the stone endoscopically, but due to the risk of bowel perforation, laparoscopic surgery was done for appendicolith removal. There was a prompt resolution of symptoms after the patient’s surgery, indicating that the fecalith was the source of the problem. Regardless of the cause, any patient with a prior scar from appendectomy with right iliac fossa pain should be suspected for a retained fecalith or one of its complications. These rare complications of surgery can easily be missed, and one must be aware of the possibility of such a rare diagnosis.Retained fecalith after appendix removal can present variably, both with respect to the onset and symptoms of presentation. Despite the rarity of this phenomenon, it is worthwhile to consider a retained fecalith as a possible differential diagnosis in any patient who presents with right iliac fossa pain with prior history of appendectomy, alongside the more common pathologies. Our case report provides a reason to consider this cause of acute abdomen even in a patient with a considerably old history of surgical appendix removal.


Clear cell acanthoma (CCA) is an unusual and benign epidermal tumor that is usually found on the limbs as a solitary reddish papule. Other variants include polypoid, giant, multiple, eruptive, and pigmented clear cell acanthoma. The typical dermoscopic pattern, known as “string of pearls”, is characterized by dotted and glomerular vessels in a mesh-like or serpiginous arrangement . Here, wA 22-year-old woman presented a slightly elevated, brownish, oval papule measuring 3 × 4 mm located on her right shoulder . The derPigmented CCA was first described by Langer et al , who repOverall, 12 cases of pigmented CCA have been described in the literature. Scheinfeld [In conclusion, pigmented CCA is a rare variant of an uncommon benign tumor with unspecific dermoscopic features, whose diagnosis is usually done relying on histological findings.


Biodentine is desirable to successfully manage internal root resorption, and the MTA apical plug backfilled with thermoplasticized gutta‐percha is suggested for the tooth with external apical root resorption. Biodentine is desirable to successfully manage internal root resorption, and the MTA apical plug backfilled with thermoplasticized gutta‐percha is suggested for the tooth with external apical root resorption. The maxillary left central incisor with chronic apical abscess was treated using MTA and thermoplasticized gutta‐percha. After 3 months, successful healing and resolution of signs and symptoms were observed.Root resorption has been described as the loss of dentin as a result of odontoclastic action. It may be a physiologic process, which can be seen in deciduous teeth or occurred due to pathologic factors such as trauma and pulpal inflammation. Root resorption is categorized into internal or external resorption based on the location of the defect in regard to the root surface. The prevalence of internal root resorption (IRR) is very low, and it may be treated inappropriately due to the wrong diagnosis. IRR is occurred when the odontoclasts start to destruct the exposed mineralized dentin under the damaged predentin and protective odontoblasts. The progression of resorption depends on the bacterial stimulation of clastic cells responsible for hard tissue destruction. IRR is commonly seen as a radiolucent area around the pulpal cavity within the dentinal wall of incisors and mandibular molars, and it is usually asymptomatic.22 as an intracanal dressing was placed by lentulo. Finally, the access cavity was sealed temporarily with reinforced ZOE. The patient was recalled 1 month later. In the next visit, obturation was performed with Biodentine capsule (Septodont) for tooth #8 (Figure This was a case of a 40‐year‐old male patient referred from a general practitioner to the department of endodontics, QUMS, with the chief complaint of pain. The patient has had a trauma caused by accident 10 years ago. His medical history was unremarkable and classified as ASA I. In clinical evaluations, extraoral examination showed no facial asymmetry and swelling. Intraoral examination showed swelling in maxillary palate and sinus tract Figure . A dislo8 Figure . After l8 Figure .In the 3‐month and 8‐month follow‐up visit Figure , tooth #3In endodontic discipline, there are many challenges about diagnosis and treatment of root resorption. Successful clinical outcome of such cases is determined by early and appropriate diagnosis of the root resorption. Differential diagnosis of IRR from other types of root resorptive defects is critical for tooth management and treatment planning by the clinician.In this case report, due to the thin and weakened structure in the resorptive defect of tooth #8, the commonly used bioactive materials, MTA or Biodentine, were suggested to be the candidates to reinforce the tooth and therefore improve the prognosis.4The early differential diagnosis and appropriate treatment are critical steps to stop the resorptive process within the pulp canal space and improve the prognosis. In the present case, due to its desirable properties, Biodentine was successfully used to manage the IRR in the maxillary right central incisor with horizontal root fracture and dislocated apical segment. Simultaneously, the MTA apical plug backfilled with thermoplasticized gutta‐percha was successfully used to obturate the maxillary left central incisor with chronic apical abscess. After 3 months, successful healing and resolution of signs and symptoms were observed.No datasets were generated or analyzed during this case report.None declared.PS: reviewed the literature, developed the concept and design of the study, performed the procedure, and drafted the manuscript. MB: reviewed the literature, involved in data analysis/interpretation, and drafted the manuscript. FN: involved in concept/design, analysis, and data collection. EM: involved in concept/design and revised the manuscript.This case report meets the ethical guidelines and adheres to Iran's local legal requirements.Published with written consent of the patient.


Primary branchiogenic carcinoma (PBC) is an extremely rare and poorly documented disease developed from a brachial cleft cyst.A 51‐year‐old patient was referred to our unit for an upper neck mass. PBC was confirmed in accordance with Kahfif's diagnostic criteria. Prophylactic selective neck dissection was performed in a second‐stage surgery to ensure the complete removal of the neoplasm. Branchiogenic origin with lymphoid tissue was confirmed in the “host cyst” after histological examination and no other tumors were found elsewhere. Regular follow up documented no relapse 12 months after surgery.Although rare, PBC must be suspected in presence of cervical masses, especially in patients older than 40 years. A standardized treatment algorithm still lacks, but prophylactic selective neck dissection could be considered as the first line choice after the diagnosis has been confirmed. Clinical examination revealed a fluctuant, painless mass close to the middle third to anterior border of sternocleidomastoid. The overlying skin appeared normal Figure . The patThe patient underwent neck dissection to remove the cyst, which appeared encapsulated. Grossly, the cystic structure measured 3.5 × 3.2 × 2.7 cm and showed a brownish, smooth external surface. Hematoxylin and eosin‐stained sections showed a cystic lumen surrounded by squamous cell epithelium. The epithelium presented a progression from benign squamous epithelium to carcinoma in situ, up to a squamous carcinoma infiltrating the cystic wall even with poorly differentiated areas  followed by fibroscopy of the upper aerodigestive tract, magnetic resonance, and PET/CT total body. Some authors suggested to perform bilateral tonsillectomy, Waldeyer's ring biopsy, or random pharyngeal biopsies in patients positive for HPV and EBV, even in absence of macroscopically suspicious lesions resulting from instrumental evaluation.Yehuda et al.4Although Kahfif et al. defined well‐established diagnostic criteria, clinical, and surgical management of PBC are still debated between Authors. Since it was firstly described by Von Volkmann in 1882, many algorithms of treatment have been proposed, ranging from conservative strategies to really aggressive ones. We recommend an early surgical treatment of all cystic masses of the neck in patients older than 40 years, eventually followed by a second stage surgery to ensure the complete removal of the neoplasm. Moreover, the existence of PBC should be considered if diagnostic criteria are respected, although its rarity.No animals were used in this research. All research procedures were in accordance with the Helsinki Declaration of 1975, as revised in 2008.The study has been approved by Institutional Ethical Committee. Informed consent for publication was obtained from the patient.The authors have stated explicitly that there are no conflicts of interest, financial supports, or otherwise in connection with this article.GC: Investigation; project administration; supervision; validation. CEB: Data curation; investigation; methodology; writing‐original draft. CS: Data curation; investigation; methodology; writing‐original draft. DD: Conceptualization; formal analysis; visualization; writing‐review and editing. IC: Data curation; investigation; methodology; writing‐original draft. MM: Data curation; investigation; methodology; writing‐original draft. GT: Supervision; validation.


Recent studies have shown a significant increase in the utilization of computed tomography (CT) scans in the emergency department for a broad spectrum of conditions. This had a significant impact on the identification of patients with serious pathologies in a timely manner. However, the overutilization of computed tomography scans leads to increased identification of incidental findings. For example, pancreatic lesions are not uncommon findings that can be identified in imaging studies performed for other indications. Here, we report the case of a 55-year-old male with a history of urinary stone disease who presented with right flank pain and dysuria. The urinalysis findings revealed numerous red blood cells and leukocytes. Non-contrast computed tomography scan of the abdomen was performed to detect urinary stones, but no hyperdense stones were noted, suggesting the possibility of spontaneous passage of the stone. However, a lesion in the pancreatic tail was observed. This exhibited fat attenuation with no solid component in the pancreatic tail representing a pancreatic lipoma. No surgical intervention was made considering the benign nature of the incidentally detected tumor. Pancreatic lipoma is a very rare benign mesenchymal tumor of the pancreas. Recognition of the classic radiological feature of pancreatic lipoma is essential to avoid unnecessary investigation and procedures. The use of cross-sectional images in the emergency department had increased significantly across a wide range of clinical presentations . While iWe present the case of a 55-year-old male who presented to the emergency department with a three-day history of right flank pain. The pain was radiating to his right groin. It was constant and stabbing in nature. He scored the pain as 8 out of 10 on the severity scale. It was exacerbated by passing urine and was partially relieved by over-the-counter analgesics. The pain was associated with nausea, vomiting, and difficulty in passing urine. There was no change in the urine color. The patient had a previous history of urinary stones, and he underwent lithotripsy three years ago. The patient is known to have hypertension, diabetes mellitus, and glucose-6-phosphate dehydrogenase deficiency. He did not undergo any previous surgeries. He was not known to have any food or drug allergies. He was a heavy smoker with 40 pack-years. He consumed alcohol occasionally. His family history was remarkable for inherited blood disorders, including beta-thalassemia and sickle cell disease.Upon examination, the patient appeared in severe pain. His vital signs revealed tachycardia 122 bpm), normal respiratory rate (15 bpm), normal temperature (36.9°C), and maintained blood pressure (130/88 mmHg). He had normal oxygen saturation on room air. Abdominal examination revealed a soft and lax abdomen with no tenderness or palpable masses. Bowel sounds were of normal intensity and frequency. Examination of other systems revealed normal findings. Routine laboratory investigations did not reveal any abnormalities. Specifically, the urea and electrolyte levels were normal  was administered to provide pain relief. The patient was asked to provide a urine sample for urinalysis. After the patient had provided the sample, he reported relief from his pain. The patient did not notice any stone while passing urine. The urinalysis findings had numerous red blood cells and leukocytes. However, the leukocyte esterase and nitrite were negative. Considering the aforementioned presentation, the initial diagnosis was a left-sided urinary stone that may have passed spontaneously. Subsequently, the patient underwent an unenhanced computed tomography scan of the kidneys, ureters, and bladder to detect any urinary stones. The scan did not demonstrate any evidence of hyperdense stones or hydronephrosis. However, a lesion in the pancreatic tail was noted. Hence, the scan was repeated with the administration of intravenous contrast. The scan revealed a non-enhancing, well-defined, lobulated lesion measuring 17 mm in the pancreatic head with fat attenuation (Figure We report an incidental finding of pancreatic lipoma in a middle-aged male with renal colic. Pancreatic lipoma is a type of pancreatic mesenchymal neoplasms, a group of tumors that arise from the non-epithelial structures of the pancreas, and they account for 1% of all pancreatic tumors . PancreaLipoma is a benign neoplasm composed of mature adipose cells within a collagenous capsule. Lipoma can develop almost in any region of the body . The exaA computed tomography scan can make the diagnosis accurately and preclude the need for biopsy and histopathological examination. As in the present case, the scan demonstrates a sharply demarcated homogeneous lesion of fat attenuation with no evidence of infiltration to adjacent structures . HoweverConsidering the rarity of the lesion, there are no established guidelines on the optimal management of lipoma. There are no definite criteria to distinguish between lipoma and liposarcoma. However, a small homogeneous lesion, measuring less than 3 cm in size, with no solid component can be diagnosed as pancreatic lipoma . PancreaSince pancreatic lipoma is benign with virtually no risk of malignant transformation, surgical resection is not warranted. However, resection of the pancreatic lipoma may be required when the tumor is large and exerts a mass effect on vital structures or there is any suspicion for malignant transformation based on radiological features ,9. The cPancreatic lipoma is a very rare benign mesenchymal tumor of the pancreas. A computed tomography scan can make the diagnosis accurately. This tumor is typically detected incidentally on cross-sectional images. Recognition of the classic radiological feature of pancreatic lipoma is essential to avoid unnecessary investigation and procedures. Since the tumor is completely benign, surgical resection is not advised in an asymptomatic patient with no suspicion of malignant transformation.


Gallbladder (GB) torsion or volvulus is a rare entity affecting elderly women. Only ~500 cases have been reported in the literature. Incidence is rare seen in ~1 in 365 520.A constant finding is the presence of the GB on a mobile mesentery. Torsion, or volvulus, of the GB occurs when it twists axially, with the subsequent obstruction of bile and/or blood flow.We briefly describe a 75-year-old female patient with acute abdomen and ultrasound and Computed tomography of abdomen revealed a distended GB. On laparotomy, we encountered a twisted GB with gangrene and cholecystectomy was done.GB volvulus is a rare occurrence and clinically mimic’s acute cholecystitis and should be sought with high suspicion especially when encountering a thin elderly woman. Immediate diagnosis is prime as delay may be fatal.Even with recent advances in imaging, it is difficult to make a correct preoperative diagnosis of GB torsion. Gallbladder (GB) torsion is a very rare clinical entity and was first described in 1896 by Wendel , 3. In lThe exact etiology of GB torsion remains unknown, although certain anatomical variants predisposing to this condition are well established . First, Torsion can be of two types. Incomplete, in which rotation is ≤180°, or complete, in which rotation is >180°. Both clockwise and anticlockwise rotations have been described; it has been proposed that clockwise rotation occurs as a result of gastric and duodenal peristalsis, whereas anticlockwise rotation is secondary to colonic peristalsis .This clinical entity is indistinguishable from those of acute cholecystitis. There have been a limited number of case reports in which a preoperative diagnosis of GB torsion was made promptly.We present a case of torsion of GB torsion which was equivocal on imaging and was confirmed by laparotomy and cholecystectomy was performed.A 75-year-old female patient was admitted to emergency room with complaints of acute abdominal pain, nausea for 2 days.3 and other biochemical parameters were normal.On physical examination, tenderness and guarding was found in umbilical region. Murphy’s sign was negative. On complete blood examination, WBC count was 14 400/mmOver distended gall bladder with thickened laminated walls filled with thick internal echoes suggestive of acute cholecystitis without gall stones were the main findings of abdominal ultrasonography . Color DOn computerized tomography, there was no additional finding .Subsequently an abdominal exploration decision was made under the guidance of physical examination signs. A median laparotomy was performed after obtaining a written informed consent from the patient.Laparoscopy for acute cholecystitis showed a reduced overall morbidity, reduced wound complications and pneumonia with reduced length of hospital stay .However, laparoscopy was not available in emergency setting in our care center, and hence a median laparotomy was performed after obtaining a written informed consent from the patient.There was purulent fluid collection in the right upper quadrant. GB was gangrenous and congested. GB had a loose mesentery and was torsioned by a rotation of 180° clockwise  and 4. CCut open of the specimen shows gangrenous mucosa .Patient postoperative period was uneventful and discharged on pod 4.Torsion of GB is an uncommon occurrence with high predilection to elderly with female to male ratio of 3:1 .The etiology of GB volvulus is unknown but some underlying factors seem to be present. First the GB is usually ‘floating’ that is where the entire organ is in contact with the peritoneum and it is connected to the porta hepatis only by the cystic pedicle. A congenital anomaly may be present where an abnormally long mesentery can suspend the GB away from the liver bed, thus increasing the chance for torsion. Likewise relaxation and atrophy of previously normal mesentery can cause visceroptosis.But for the torsion to occur a triggering event has to occur. Liver atrophy, loss of visceral fat and elasticity, weight loss, atherosclerosis of the cystic artery and spinal deformities have all been theorized as possible triggering factors , 8. InteSymptoms of GB torsion are usually nonspecific and mimic those of acute cholecystitis. There may be complete or incomplete torsion. Torsion with a degree of rotation of <180 is defined as incomplete and it mimics biliary colic.In complete torsion, GB perfusion is deteriorated, and patients show the signs of acute cholecystitis. Examination findings may be nonspecific, but many will have clinical signs of acute cholecystitis at admission. Laboratory studies are usually nondiagnostic.Preoperative diagnosis is difficult with fewer than a dozen cases found in the literature. Most diagnoses are made intraoperatively.In this case, we performed a laparotomy due to the equivocal nature of the imaging studies and we found a long mesentery with 180° clockwise torsion with gangrenous gall bladder and cholecystectomy was performed.GB volvulus is a rare occurrence should be suspected in all patients presenting with signs and symptoms of acute cholecystitis, especially if they are elderly thin women. Delay in treatment can lead to necrosis, perforation and peritonitis and hence immediate diagnosis and management are of prime importance.Study concept and design—Dr P. Sai KrishnaData collection—Dr P. Sai KrishnaEditing—Dr R.D.R SomasekarData analysis or interpretation—Dr A. SivasankarWriting the paper—Dr R.D.R SomasekarNone declared.None.Ethical approval was obtained—Committee—Govt. Mohan Kumaramangalam Medical College Hospital.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.Available on request.


A wide variety of benign and malignant tumors can arise from different structures in the orbital and peri-orbital area, affecting the eye and the optic nerve. This spectrum of tumors includes primary and metastatic carcinomas, lymphomas, melanomas, soft tissue tumors, and primary tumors of the retina, optic disc, and optic nerve. These also extend to relatively rare entities such as solitary fibrous tumor and meningioma of the orbit and optic nerve, which can present with very similar clinical and radiologic features, although the tumor grades, treatment plans, and outcomes can vary widely. In this report, we present two clinical cases of solitary fibrous tumor [central nervous system (CNS) World Health Organization (WHO) grade 2 and 3) and compare their clinical presentation, radiologic and histologic features, treatment, and clinical outcomes to a group of three orbital meningiomas (CNS WHO grade 1 and 2). In the context of these five cases of orbital lesions, we review the current clinical, pathologic, and radiologic literature on orbital tumors, focusing primarily on solitary fibrous tumors and meningiomas, along with an expanded discussion on the diagnostic criteria of both entities, as well as the treatment and prognosis of these lesions. Nonmetastatic neoplastic processes affecting the meninges can be broadly categorized as meningeal or mesenchymal. Meningiomas were first characterized in modern literature in 1922  and is rHere, we evaluated two patients with CNS World Health Organization (WHO) grade 2 and 3 solitary fibrous tumors of the orbit and compared their initial presentation, radiologic features, histologic findings, and clinical outcomes to three patients diagnosed with CNS WHO grade 1 and 2 meningiomas of the orbit. In addition, we review the literature to discuss the radiologic features associated with the orbital presentation of these two tumor entities.MethodologyHistologic PreparationsHematoxylin and eosin (H&E)-stained slides for all cases were prepared from 4 μm thick sections of formalin-fixed, paraffin-embedded (FFPE) tissue using standard protocols. Immunohistochemistry was performed on 4 μm paraffin sections following heat-induced epitope retrieval using CC1 , followed by staining with signal transducer and activator of transcription 6 (STAT6) , cluster of differentiation (CD) 34  progesterone receptor (PR) , epithelial membrane antigen (EMA) , somatostatin receptor 2 (SSTR2) , and Ki-67  on either a Ventana Benchmark XT or Ventana Benchmark Ultra automated stainer, using Ventana UltraView Universal DAB Detection kits.Next-Generation SequencingTargeted genome sequencing was performed on DNA isolated from FFPE tissue using next-generation sequencing (NGS) panels to evaluate 324 genes and gene rearrangements, microsatellite instability (MSI), and overall tumor mutation burden (TMB) in case 2 .Case reportsCase 1A 53-year-old man presented with a six-month history of progressive blurry vision, right-sided proptosis, and restricted upward gaze. Magnetic resonance imaging (MRI) revealed a 3.3 × 3.2 × 1.8 cm T1/T2 isointense, diffuse, space-occupying mass with homogenous enhancement on T1 with gadolinium contrast in the superior right orbit with mild depression of the right eye Figures -1C. He uCase 2NAB2-STAT6 fusion.A 37-year-old man presented with a two-year history of gradual visual loss in his right eye and mild right exophthalmos. Imaging revealing a 4.7 × 4.3 × 3.6 cm lobulated, homogenously enhancing mass along the floor of the anterior middle cranial fossa involving the right sphenoid bone, sphenoid sinus, and projecting into the cavernous sinus and posterior orbit with involvement of the optic canal and internal carotid artery Figures -3C. The The final diagnosis was SFT, CNS WHO grade 2. Postoperatively, the patient was referred to radiation oncology for post-treatment radiation therapy, yet he continued to have worsening right eye vision loss and cranial nerve III palsy, with postsurgical imaging showing residual tumor. He underwent external beam radiotherapy, and, as of this manuscript’s composition, is currently alive, with a 33-month follow-up demonstrating retained right upper inner quadrant vision and imaging showing stable postsurgical changes. He is scheduled for continued follow-up and imaging studies.Case 3A 38-year-old woman who initially presented for evaluation of left-sided proptosis was found to have a left orbital mass depressing the globe inferiorly on MRI. There was an extension of enhancement in the left sphenoid along the orbital, lateral frontal, and temporal dura Figures -4C. A biThe first orbital resection specimen in 2013 was most consistent with meningioma, CNS WHO grade 1. The microscopic evaluation demonstrated meningothelial cells infiltrating bone and muscle with bland cytology. No mitotic figures were identified. However, there were areas of fibrous change consistent with transitional meningioma. The tumor demonstrated a Ki-67 proliferation index of 4-6% with focal EMA and S-100 positivity. PR immunohistochemistry was negative. The second orbital resection specimen was most consistent with atypical meningioma, WHO grade 2. The microscopic evaluation demonstrated islands of cells with round to oval nuclei with poorly defined cell borders and nuclear pseudo-inclusions adjacent to muscle. Up to seven mitotic figures were identified in 10 HPFs. The tumor demonstrated a Ki-67 proliferation index of 12-15%. The tumor cells were positive for EMA and focally for PR.During her one-year follow-up after the second resection, the patient denied any worsening of her vision. However, her headaches, which she had been experiencing for several decades, persisted; this was attributed to a medical history of trigeminal neuralgia.Case 4A 47-year-old woman presented with a six-month history of worsening vision and left eye proptosis. A brain MRI revealed a 1.8 × 0.9 cm homogenously enhancing extracranial mass in the right frontal lobe with a dural tail and a second homogenously enhancing mass in the left orbit measuring 1.8 × 0.6 cm and extending into the left optic canal Figure . The patCase 5An eight-year-old female initially presented to the emergency department due to a four-month history of left eye proptosis, strabismus, and progressive blindness. A computed tomography (CT) scan of the head demonstrated a 2.5 × 1.7 × 2.0 cm intraconal mass surrounding the optic nerve sheath and extending into the left medial rectus muscle. Posteriorly, the mass extended all the way to the apex of the left orbit, involving the left superior orbital fissure , detailing the multidisciplinary aspects of clinical presentation, radiological workup, and histopathology of these neoplasms. Due to their location, the number of adjacent structures, and the wide differential diagnosis, these neoplasms present a relatively unique set of radiologic and surgical challenges.Meningeal SFT is a mesenchymal fibroblastic tumor first reported in the pleura , soon foNAB2-STAT6 fusion proteins [NAB2ex4-STAT6ex2/3, corresponding to the classic pleural/pulmonary SFT, and the second most frequent NAB2ex6-STAT6ex16/17, commonly found in younger patients [The 2016 WHO Classification of Tumours of the Central Nervous System revised 4th edition combined SFT and HPC into a single entity based on their shared high frequency of proteins ,12. Bothproteins . Whole-gproteins ,14 have patients . SFT caspatients ,15,16.The proposed grading criteria somewhat vary between the updated CNS classification system (with continued studies attempting to improve the CNS grading system ), the WHThe clinical behavior of SFT depends on the extent of surgical intervention and the presence of high-risk features in the orbit. WHO grade 1 SFTs reported within the CNS have a good prognosis, while those with WHO grade 2/3  featuresONSMs are rare, benign tumors of the CNS. In a case series performed by Shields et al., ONSMs were found to represent approximately 2% of all orbital tumors. Of all meningiomas, ONSMs constitute approximately 1-2% of all lesions . They moClinically, ONSMs present with the classic triad of optic atrophy, visual loss, and the presence of opticociliary shunt vessels . The mosThe gold standard for visualization of ONSMs is MRI. CT can also allow the visualization of the lesion; however, only MRI can clearly delineate the optic nerve as it traverses through the optic canal . SimilarOrbital SFTs are low-grade lesions usually present in the extraconal space of the orbit  . They arDifferential diagnoses for vasculogenic lesions of the orbit include cavernous malformations, which are the most common benign lesions of the orbit and are typically well-circumscribed. However, they occur at the lateral aspect of the intraconal space . Rarely though, conal and extraconal cavernous malformations may occur. Cavernous malformations  do not cAnother differential of orbital lesions is lymphoma (primary or systemic), which often cannot be reliably differentiated on images. Usually, lymphoma is seen in the extraconal ,35 compaOrbital or ONSMs occur in the intraconal compartment and show a classic tram-tracking appearance , as seenDifferentials for extraconal lesions on imaging in addition to SFTs include peripheral sheath tumors such as schwannoma and neurofibromas. Schwannomas appear hyperintense on T2-weighted images such as cavernous malformations; however, a differentiating feature of schwannomas is their heterogeneity on T2 due to mixed solid and cystic components . On postWhen managing patients with ONSM and orbital SFT, the primary goal of treatment is the preservation of vision and, if possible, prevention of tumor progression. When left untreated, these lesions almost always result in visual deterioration. Historically, management of ONSM has involved careful observation in cases where there is negligible visual decline. However, inevitably, up to 85% of patients experience visual decline, warranting medical intervention . UnfortuOrbital SFTs, given the wide differential diagnosis for an orbital tumor, can make for a difficult diagnosis. The location and proximity to several structures also pose a treatment challenge. In this case series, we have highlighted radiographic and histological features of both SFTs and ONSMs diagnosed at our institution, outlined their clinical outcomes, and reviewed the literature on clinical, radiologic, and pathologic features of SFTs, as well as other possible orbital tumors. The clinical outlook for SFTs is variable and depends not only on tumor grading but also on the presence of high risk, which if present usually suggests a need for adjuvant radiotherapy to decrease the risk of recurrence and extracranial metastasis. Our patients diagnosed with SFT were either CNS WHO grade 2 or 3 and thus had radiation oncology on board, with both currently remaining clinically stable. In contrast, ONSMs, also on the differential for an orbital tumor, are benign but problematic given their impact on visual function. Generally, the primary goal of treatment for SFTs and ONSMs is the same, that is, to preserve visual function. While surgery alone is often utilized for the management of ONSM, adjuvant radiotherapy helps avoid total resection, which is associated with a higher risk of visual compromise.


Isolated fallopian tube torsion is an extremely rare occurrence in a young female. The lady concerned presented with acute abdominal pain and the ovaries were normal on the scan with dilated fallopian tubes. On laparoscopy, it was revealed that she was suffering from fallopian tube torsion and laparoscopic salpingectomy was performed. The patient recovered well postoperatively. Isolated torsion of the fallopian tube is an extremely rare occurrence in a female patient presenting with acute lower abdominal pain. It does not have any classical signs and symptoms which would prompt an accurate diagnosis. The diagnosis usually comes late and is usually confirmed only on laparoscopy where the gangrenous tube can rarely be salvaged. Strikingly, the ovary can be salvaged in maximum number of cases.The lady concerned was a 22-year-old girl who presented in A&E department with presentation of pain in the left iliac fossa for 5 days. The pain was throbbing in nature. She reported an intensity of about 8/10. There was no association with any bladder or bowel symptoms. There was no previous significant medical or surgical history.On examination, she was tachycardic with a pulse rate of 120 bpm. She was normotensive and apyrexic. On examination, she was found to be tender in the region of left iliac fossa. The uterus was found to have a normal size with reduced mobility. There was a lump palpable on the left adnexa on per vaginal examination.Her blood investigations revealed that she was suffering from anemia (Hb—95 gm/dl), increased white cell count, and increased CRP.On imaging, there was a lump seen on the left adnexa (separated from the ovary) on both transvaginal ultrasound and CT scan of lower abdomen on pelvis. Figures 1The uterus was found to be anteverted and anteflexed measuring 9.3 cm × 6 cm × 4 cm. Both ovaries appeared morphologically normal. Right sided fallopian tubes appear normal. Left sided fallopian tube appears dilated—2 × cystic structure noted around the tube measuring 4 cm × 4.4 cm and 2.6 cm × 3.3 cm. There is no free fluid in the pouch of Douglas. Extreme probe tenderness was noted on the left adnexa. Provisional diagnosis: hydrosalpinx—left sided tubo ovarian abscess.On provisional diagnosis of tubo-ovarian abscess, she was consented for laparoscopy ± proceed. On laparoscopy, the left fallopian tube was found to be gangrenous and edematous due to complete torsion. Left sided complete salpingectomy was performed on the same sitting. She was shifted to the ward after the operation, and she was discharged on the next day. Her postoperative first follow-up was scheduled after 7 days, and her postoperative follow-up was uneventful.On microscopy, there is dilating tubular specimen presumably the fallopian tube which has lost its mucous, and plicae show extensive uniform interstitial haemorrhage probably due to torsion, most likely in keeping with clinical history of torsion. There is no chorionic villous or dense fibrosis or decidua to suggest ectopic gestation.Diagnosis: left fallopian tube—torsion with haemorrhage.Ovarian torsion and acute appendicitis are the close differential diagnosis which might put the diagnosis in dilemma.The patient recovered uneventfully in the next postoperative day. The lady was reviewed at 6-week follow-up, and she did not have any specific complaint.Fallopian tube torsion is a rare but known etiology of acute abdominal pain in a young womenThe ovaries might appear normal on ultrasound and CT scan, but the entire clinical picture must be taken into account before reaching a diagnosisThe recommended management is laparoscopic fallopian tube detorsion if the tube is still viable. If gangrenous, laparoscopic salpingectomy is the preferred optionThough it makes us deeply concerned that our daughter has lost one of her tubes at a so young age, yet we understand that as there was a risk of sepsis associated with the condition, if not acted promptly. Though being unfortunate, we feel greatly relieved that timely intervention by the team of doctors has prevented any further catastrophe to take place. (The patient's mother)Isolated fallopian tube torsion has been described as being a rare cause of lower abdominal pain in women.  It was f


Epithelioid trophoblastic tumours are rare neoplasms showing differentiation towards the chorion leave-type intermediate cytotrophoblast, with only a handful of cases being reported in the literature. These tumours are slow-growing and are typically confined to the uterus for extended periods of time. While the pathogenesis is unclear, they are thought to arise from a remnant intermediate trophoblast originating from prior normal pregnancies or, less frequently, gestational trophoblastic tumours. A protracted time period between the gestational event and tumour development is typical. This case describes a 49-year-old previously healthy female who presented with a completely asymptomatic uterine mass, discovered incidentally during a routine gynaecological assessment. The pathological analysis of the hysterectomy specimen confirmed an epithelioid trophoblastic tumour, involving the uterus and cervix. This is a rare gynaecological tumour. A comparative short tandem repeat analysis revealed genetic similarities to a previous healthy gestation seventeen years prior. She was successful treated with adjuvant pembrolizumab, with no evidence of disease recurrence to date. Epithelioid trophoblastic tumours (ETT) are distinct, rare neoplasms arising from a chorionic-type intermediate trophoblast. We describe a case of a middle-aged female who was diagnosed with an ETT following the incidental detection of a uterine mass during a routine gynaecological assessment. Tumour genetic analysis revealed a link with a healthy gestation seventeen years prior.A middle-aged female was referred from a private clinic in May of 2020 for investigation of a suspicious uterine mass incidentally detected on ultrasonographic studies. The patient was a 49-year-old female who was being followed up routinely by her private gynaecologist. She was completely asymptomatic and denied menorrhagia, post-coital bleeding, or vaginal discharge. She had suffered from heavy menstrual bleeding in 2012 and had been successfully treated with a levonorgestrel-releasing intrauterine system. She was a mother to two healthy children, with a female child born in 2003 and a male child born in 2006. Both children were born by normal vaginal delivery and no obstetric complications were reported. There was no history of miscarriages. She had no significant medical or surgical history of note and was not on any regular medications. Gynaecological examination revealed a bulky uterus, comparable to the size of a fourteen-week gestation.2 soft tissue circumferential mass arising from the lower uterus, showing an intermediate T1 and T2 signal. The mass had a 1.5 cm cystic component centrally. The tumour distorted the uterine cavity, but did not extend into the cervix or para-uterine space. No enlarged pelvic lymph nodes were identified , cancer-antigen 125 (CA 125), and cancer antigen 19.9 (CA 19.9) were within normal limits and β-human chorionic gonadotrophin (βhCG) levels were normal, at 1.4 mIU/L . Computed tomographic assessment showed a 7 cm mass in the uterus, centred on the cervico-uterine junction. Magnetic resonance imaging showed an approximately 5 × 6 cmentified . The masIn view of the strong radiological suspicion of malignancy, following discussion with the patient, a routine total abdominal hysterectomy and bilateral salpingo-oöphorectomy were carried out. The surgical assessment of the abdomen and pelvis showed no gross evidence of metastatic disease. A biopsy of the greater omentum was also submitted for pathological analysis.The pathological analysis of the uterus showed the presence of a mass, centred on the posterior aspect of the lower uterine segment, measuring 55 mm in its greatest dimension. The mass had a tan-brown, focally haemorrhagic cut surface and showed foci suspicious for necrosis. The tumour was relatively well-circumscribed, but extended into the posterior cervical lip. The tumour was associated with minimal distortion of the uterine cavity. The rest of the uterus and both adnexae were grossly unremarkable.The histopathological analysis showed a tumour comprised of atypical mononucleate epithelioid cells with abundant eosinophilic cytoplasm and ill-defined cell membranes, organised in infiltrative nests and sheets . ScatterThe immunohistochemical studies showed a strong and diffuse expression of cytokeratin stains (MNF116 and AE1/AE3), together with placental alkaline phosphatase (PLAP), inhibin, epithelial membrane antigen (EMA), and E-cadherin. The differentiation towards a chorion leave-type intermediate trophoblastic lineage was further confirmed with strong expression p63, very focal expression of βhCG, and absent mucin-4 (MUC4) staining. A Ki67 proliferation fraction of 20% was demonstrated immunohistochemically . The finThe tumour infiltrated the outer half of the myometrium together with the upper cervix. However, the tumour did not reach the serosa or the uterine parametrium, and the excision was deemed to be complete, with a Fédération Internationale de Gynécologie et d’Obstétrique (FIGO) stage I disease. The omentum was free of metastatic disease.A comparative short tandem repeat genotypic analysis was performed, comparing the tumour genotype with that obtained from saliva samples taken from the patient, the biological father of both her offspring, and both offspring . The preFollowing an uneventful post-operative recovery, as in the case of all local cases of gestational trophoblastic disease, this patient was referred to the Charing Cross Gestational Trophoblastic Disease Service in London, UK. This case was diagnosed during the COVID-19 pandemic (June 2020) and prior to the availability of any COVID-19 vaccinations. At this time, many hospital services were disrupted and there were restrictions on air travel. Since genetic testing linked the ETT to the conception in 2003, the case was deemed to be of high risk and a treatment with pembrolizumab was recommended. This was the preferred treatment option to minimize the risk of neutropaenic episodes. Therefore, the patient was started on pembrolizumab at a dose of 200 mg every three weeks, in accordance with the NHS England Guidelines on the use of Pembrolizumab for Gestational Trophoblastic Neoplasia. She suffered no therapy-related complications and both computed tomographic imaging studies and pelvic magnetic resonance imaging showed no evidence of locoregional recurrence or distant metastatic disease within a twelve-month follow-up period.Gestational trophoblastic disease constitutes a group of disorders caused by pathological aberrations occurring during placental development. These diseases can be broadly subclassified into three distinct groups: benign trophoblastic lesions , hydatidiform moles , and true gestational neoplasms , with the latter group representing neoplasms recapitulating various stages of placental development .The earliest stage of embryonic trophoblastic differentiation is represented by the trophectoderm, which forms as the outermost layer of the blastocyst. The trophectoderm adjacent to the inner cell mass subsequently differentiates, forming cytotrophoblast together with an early multinuclear primitive syncytium, the latter playing a key role in the early invasion of the maternal vasculature to form blood-filled sinusoids. These sinusoids are subsequently permeated by the cytotrophoblast, forming primary villi, which then develop into secondary villi after the migration of the extraembryonic mesoderm, originating from the embryonic disk . The cytETTs are rare malignancies, with approximately 140 cases described worldwide. These tumours were first classified as a distinct entity by Shih and Kurman in 1998, who described the first cohort of 14 cases. In this series, all tumours were localised to the uterus, cervico-uterine junction, or cervix, and were histologically characterised by sheets and islands of trophoblastic cells, with extensive geographic necrosis, associated extracellular hyaline-like matrix, and scattered calcifications .ETTs bear a strong association with prior gestational events, most frequently normal vaginal delivery together with molar gestations and abortions . HoweverTwo additional unique features of this case warrant mentioning, in particular the complete absence of clinical symptoms together with normal serum βhCG levels. Most patients present with abnormal vaginal bleeding, amenorrhea, abdominal pain or bloating , and oftOn the histopathological analysis, the differentiation towards chorionic-type intermediate trophoblast is confirmed through the expression of inhibin-α, PLAP, p63, EMA, broad range cytokeratin, and E-cadherin, together with a weak expression of human placental lactogen and βhCG . Given tThe behaviour of ETT is difficult to predict; however, within the limits of the data currently available, it appears to be similar to placental site trophoblastic tumours . The metNo standard treatment protocols are available for the management of ETTs given that large-scale clinical trials are not possible owing to their inherent rarity. ETT, similar to placental site trophoblastic tumour, is a chemoresistant neoplasm. While adjuvant therapy with various combinations of etoposide, cisplatin, actinomycin D, methotrexate, and paclitaxel have been successfully used, a case-by-case approach is mandatory as reports of cases of patients having been successfully treated with radical surgery to remove metastatic or recurrent disease have been documented ,14,15,16In this paper, we describe a case of an epithelioid trophoblastic tumour in a 49-year-old female with genetic linkage to a gestational event seventeen years prior, with an interim unrelated second normal gestation. The patient was successfully treated with surgery and adjuvant pembrolizumab, the latter being a relatively novel agent used in the treatment of these rare neoplasms. The patient was completely asymptomatic and had normal serum βhCG levels, both being unusual for this disease entity. The unusual, albeit distinct, histomorphology and immunophenotype of ETTs are emphasised to avoid diagnostic pathological pitfalls with other neoplastic entities.


Congenital lumbar hernia is a rare disease affecting mainly infants. Its association with lumbo-costo-vertebral syndrome (LCVS) is hardly seen in the literature. We present a case of LCVS in a 1-month-old female infant presenting with a soft bulge in left lumbar region. Abdominal X-ray revealed absence of multiple ribs with a mild lumbar scoliosis and defective ninth vertebra. Ultrasonography showed absence lateral abdominal wall muscles in left lumbar region and 2.5 cm diameter lumbar hernia. Primary repair of the adnominal wall defect was performed without meshplasty and no recurrence was reported. We hope to enhance the literature of this rare disease with our case. Congenital lumbar hernia (CLH) is a rare entity, which is scarcely reported in the English literature . The lumA 1-month-old girl presented to the surgery department with a left-sided lumbar bulge , which wPhysical examination revealed a soft mass in the left lumbar region with no abnormalities on overlying skin and no splanchnomegaly. She weighed 3.2 kg at presentation. Examinations of her reflexes, cardiac system and anus were all normal.Abdominal X-ray revealed absence of the left 10th to 12th ribs along with half of the 9th rib and a mild lumbar scoliosis . The shaAfter studying the case, we decided to perform primary repair of the abdominal wall defect without meshplasty since the diameter of the aperture was <5 cm. An oblique left lumbar incision was performed above the hernia, revealing a defect measuring 4 cm in diameter in the upper lumbar triangle. Dissection of the peritoneum and hernial sac was performed starting from the margins of abdominal muscles , the heret al. [CLH is one of the rarest varieties of abdominal parietal hernias. In 1672, Barbette was the first to suggest the existence of lumbar hernia, whereas the first case of CLH was reported by Garangeot in 1731 [et al. , but stiet al. [et al. [According to a case series done by Sharma et al. , the med [et al.  showed oLesshaft found that the superior lumbar triangle developed the hernia more commonly than the inferior lumbar triangle, since the superior lumbar triangle has congenital weak points in its floor, where the 12th dorsal neurovascular bundle perforates the transversalis fascia . But theThe hernia may be apparent in the newborn, but it typically presents in an older infant as a lumbar mass, which worsens upon crying. The hernial content consists most commonly of intestines, but the spleen or kidney can be found rarely . ComputeIn order to create a consistent literature on a specific rare disease, it must be sufficiently equipped with enough cases so that it can give realistic answers and insights and prevent unnecessary doubts and misunderstandings.


Teratoma is the second most common mediastinal neoplasm, but malignant transformation in mature teratomas is uncommon, and cases of carcinoid tumor with teratoma are described in only a few studies. In addition, multilocular thymic cyst associated with mature mediastinal teratoma is also a rare entity. There have been no reports of case with the coexistence of these three pathological lesions.The patient was a 24-year-old man who was referred to our hospital due to a 2-day history of left shoulder pain, a feeling of severe chest tightness and high fever. Pre-operative computed tomography (CT) showed a large, fluid-filled and well-demarcated multilocular cyst in the anterior to superior mediastinum measuring up to 12 cm in size. Contrast-enhanced CT also revealed that the tumor contained a solid component with slight contrast enhancement and spotty wall-thickening septation. Therefore, cystic thymoma, thymic cyst, cystic teratoma, or germ cell tumor with an inflammatory reaction were considered as differential diagnoses. The patient underwent tumor extirpation under median sternotomy. The pathological diagnosis was multilocular thymic cyst with mature teratoma including carcinoid tumor (Grade 2) in the mediastinum.The relationship between thymic cyst, teratoma and carcinoid tumor is unclear at present; therefore, further research is needed to clarify the relationship between these entities. In this report, we present a case of multilocular thymic cyst with mature teratoma including a carcinoid component in the mediastinum that was detected by complete surgical resection. Carcinoid tumor arising from a mature mediastinal teratoma is very rare, with only a few documented cases. Furthermore, thymic cyst associated with mature mediastinal teratoma is also extremely rare. To the best of our knowledge, the simultaneous presence of these three pathological lesions has not been described in the literature. We herein report the first case of a patient who histopathologically presented with a multilocular thymic cyst associated with mature teratoma including a carcinoid component in the mediastinum.The patient was a 24-year-old male who presented with a 2-day history of left shoulder pain, a severe feeling of chest tightness and high fever. His family medical history was not significant, and he had not received a medical checkup for more than 5 years. Chest X-ray showed an abnormal mass in the left hilar region Fig. . A bloodWe decided to surgically remove the cystic tumor because of the possible coexistence of varied malignancies, the exacerbation of infection or the possibility of tumor rupture, including hemorrhaging or penetration to the surrounding structures. Following antibiotics treatment, tumor extirpation under median sternotomy was performed one week after the onset. During surgery, a well-encapsulated, thick-walled, and elastic hard cyst was observed in the superior to anterior mediastinum that was closed to the left brachiocephalic vein and pericardium. Since the adhesion between the tumor and pericardium was moderately strong, combined resection of the pericardium was performed and pericardium reconstruction was performed. The tumor was 12 × 10 × 6 cm in size with grayish-white discoloration Fig. . The cutBased on these findings, the pathological diagnosis was multilocular thymic cyst associated with carcinoid tumor (Grade 2) arising from mature mediastinal teratoma. The patient was discharged without any post-operative complications and was followed up for 1 year after surgery without any recurrence.Mediastinal teratoma is a rare disease; however, it is the most common mediastinal germ cell tumor, with no significant sex difference, and can occur at any age, most commonly in individuals of 20–40 years of age. It accounts for 5–10% of all mediastinal tumors . The coeThymic cysts are benign entities that are classified as congenital or acquired entities in origin and are usually diagnosed in the first two decades of life. They account for only 2–3% of all mediastinal cysts –13. CongIn the present case, the histological sections showed two distinct lesions. The first was a benign multilocular thymic cyst composed of underlying squamous cells and lymphoid tissues. Secondly, close to this cystic lesion, there was a grayish-white solid component which had various organ cells, confirming mature teratoma. In a small part of it, carcinoid differentiation (size: 6 × 3 mm) was observed. The relationship between the thymus and the tumor was unclear, although there was residual thymic tissue that existed adjacent to the mature teratoma with a carcinoid component. Complete surgical resection and a detailed histological evaluation were useful for making an accurate diagnosis and treatment, and led to a good prognosis.Regarding treatment of mediastinal tumors, emergency surgery should be considered in cases such as ours, since the possible resulting mediastinitis and pleurisy have a high risk of causing mortality. According to the literature review by Nakajima et al., surgical resection for ruptured teratoma in mediastinum was performed 1 week after the onset of rupture in 48% of patients . The sudWe reported an extremely rare case of multilocular thymic cyst associated with mature teratoma including a carcinoid component in the anterior mediastinum, which was successfully extirpated.


Necrotizing soft tissue infection (NSTI) of the chest wall is a rare, rapidly spreading, highly lethal surgical disease. Radical debridement interferes with the important anatomical function of the chest wall. We report a case of chest wall NSTI that was successfully managed with early diagnosis and serial debridement.A 43-year-old, previously healthy woman presented with severe malaise and worsening right axillary pain. She was severely lethargic and had a painful, large, pale lesion with surrounding erythema of the right chest and trunk. Computed tomography revealed NSTI, with diffuse soft tissue inflammation extending from the axilla to the lower abdomen. There was no obvious entry portal. Prompt surgical drainage was established. Group A streptococcus infection was diagnosed. During her 3-month postoperative course, she underwent four more surgeries, including two debridements. This treatment proved successful and avoided the need for complicated muscle flap reconstruction. She was discharged on postoperative day 109.Group A streptococcus can cause NSTI even in immunocompetent patients without an entry portal. Radical debridement is recommended for infection control. Preserving anatomical chest wall function, however, is also important. Serial debridement with close follow-up solved the problem in this patient.Serial debridement with close follow-up enabled to avoid large tissue deficits and complicated reconstruction in the case of NSTI of the chest wall. •Necrotizing soft tissue infection of the chest wall is rare and lethal.•Radical debridement could interfere with the anatomical function of the chest wall.•Adequate drainage with minimum skin incision avoids large tissue defects.•Serial debridement with close follow-up enabled to avoid complicated reconstruction A revie2A previously healthy 43-year-old Japanese woman presented with a 3-day history of fever and worsening right axillary pain. On admission, the pain was accompanied by severe malaise that rapidly progressed. She denied trauma or recent surgery. Her past medical history was insignificant (cesarean section >10 years previously). She was afebrile but tachypneic. Physical examination showed a large, pale lesion with surrounding erythema on the right chest and trunk a. She waThe patient was placed in left decubitus position for the surgery. Two 10-cm transverse incisions were made. The cephalad line was at the height of the nipples to accommodate drainage between the pectoralis and latissimus dorsi muscles. The caudal line, at the height of the umbilicus and lateral to the rectus muscle, was used for drainage between the external and internal oblique muscles and the inguinal region b. Blunt Streptococcus pyogenes, these antibiotics were replaced with penicillin G and clindamycin. Antibiotics were administered until POD 18. On POD 11, additional debridement was deemed necessary because further necrosis was found in preserved skin around the abdominal wound,  has been reported as safe, and it saves skin and soft tissue if needed for flaps to treat Fournier's gangrene . At her 4NSTI should be highly suspected even at atypical sites in patients without predisposing conditions. Serial and optimized-range debridement may prolong the postoperative course but enabled to minimize skin and soft tissue deficits and to avoid complicated reconstruction.All authors have no conflict of interest about this study.


Vasitis nodosa involves benign, reactive spindle-shaped nodular thickening of the ductal epithelium of vas deferens. We report the case of a 21-year-old male with a history of bilateral undescended testes and left orchidopexy. The patient presented with the complaint of a non-tender left inguinal swelling. The definitive diagnosis of vasitis nodosa was made based on clinical evaluation and imaging findings. We suggest that this rare entity should be considered as a differential diagnosis of inguinal swelling during the assessment of the male urogenital system. Vasitis nodosa refers to a benign condition, in which the ductular epithelium of the obstructed vas deferens undergoes reactive proliferation, forming fusiform nodular thickening. It may occur following an infection or either surgical or non-surgical trauma. Only 90 well-documented cases have been reported so far since the first description of the disease in 1943 . ClinicaOur patient was a 21-year-old male with no known comorbidities, who presented with the complaint of swelling in the left inguinal region for three months. He had a history of bilateral undescended testes for which he had undergone left orchidopexy at the age of eight years. Agenesis of the right testis was noted at the time of surgery. He had no history of fever, trauma, tuberculosis, alcohol consumption, cigarette smoking, or high-risk sexual behavior. On examination, there was swelling in the left inguinal region, which was non-tender on palpation. There was no associated erythema or pigmentation.6/mL) with a semen volume of 2.2 mL , seminal fructose of 15 µmol/ejaculate  and pH of 7.4 . His urine D/R showed a pH of 5.5  with occasional leukocytes of 7 white blood cells (WBCs)/hpf .Laboratory investigations displayed serum electrolytes: sodium 142 mEq/L , potassium 4.6 mEq/L , chloride 104 mEq/L , and bicarbonate 24 mEq/L . The rest of the parameters were hemoglobin 14.2 g/dL  and platelet count of 258,000/mcL . Prothrombin time was 11.5 seconds  and international normalized ratio was 1.05 . C-reactive protein was 12.4 mg/L  indicating ongoing inflammation. His semen analysis revealed azoospermia  and a luminal diameter ranging from 0.2 to 0.7 mm  [ Kovi and Abgata have reported the benign neural invasion in cases of vasitis nodosa, emphasizing the fact that it can mimic low-grade adenocarcinoma of vas deferens . The exaVasitis nodosa is a rare entity and should be considered as a differential diagnosis for inguinal swelling, especially in patients with a history of undescended testes, vas deferens, or perineal surgery. Clinical presentation with asymptomatic inguinal swelling resulting from vas deferens nodularity requires no treatment. CT and MRI scans can play a critical role in diagnosis to prevent unnecessary surgical procedures.


Ileoileal knotting is one of the rarest causes of intestinal obstruction. The pathology involves knotting of the ileum around itself, leading to mechanical intestinal obstruction that can rapidly evolve to gangrene.Here we will discuss the case of an 18-year-old Oromo girl who presented with sudden onset of severe abdominal pain and signs of generalized peritonitis.Ultrasound examination showed massive peritoneal and cul-de-sac fluid. Explorative laparotomy was done, with a tentative diagnosis of ruptured ovarian cyst. Intraoperative finding was a gangrenous ileoileal knot. The gangrenous segment was resected and ileotransverse anastomosis done. Postoperative course was uneventful, and the patient was discharged improved on the sixth postoperative day.We present this case to highlight the diagnostic difficulty that one can face in females of child-bearing age and to create awareness of this rare cause of intestinal obstruction, as morbidity and mortality are very high because of rapid progression to gangrene. One of the most common surgical emergencies worldwide is intestinal obstruction, with small bowel obstruction (SBO) accounting for the majority of cases . IntestiAn 18-year-old Oromo high school student initially presented to the emergency gynecology department of Ethio-Tebib Hospital, Addis Ababa, Ethiopia with 12 hours history of severe crampy abdominal pain. It was initially periumbilical and later became generalized. Associated with this, she had repeated vomiting that initially consisted of ingested matter and later became bilious. She also had two episodes of watery diarrhea, yellowish in color. She had history of irregular menses, and her last cycle was 6 months back. She did not have history of previous abdominal surgery and gave no history of abdominal trauma. On physical examination., blood pressure (BP) was 120/70 mmHg, heart rate 112/minute, respiratory rate (RR) 26 breaths/minute, temperature 36.5 °C ,and oxygen saturation 98%. She had pink conjunctivae and dry buccal mucosa. Pertinent physical examination finding was on the abdomen, which was full and showed no movement with respiration, with diffuse direct and rebound tenderness. Bowel sounds were hypoactive, and digital rectal examination was tender anteriorly and showed no mass with well-formed stool on examining finger. Per vaginal examination was deferred as she was a virgin. Laboratory tests were all normal, including urine human chorionic gonadotropin (HcG) which was negative; however, abdominopelvic ultrasound showed massive free peritoneal and cul-de-sac fluid. Diagnostic paracentesis showed hemorrhagic fluid. With a diagnosis of acute abdomen with generalized peritonitis and hemoperitoneum secondary to ruptured ovarian cyst, she was resuscitated with intravenous normal saline and taken to the operating theater. Upon exploration, there was 500 ml of hemorrhagic fluid and gangrenous distal ileum seen caught in a knot formed by the proximal ileum (Fig. Intraoperative consultation of surgical department was done. The entangled segment was released and around 100 cm of gangrenous bowel resected Fig. . There wIntestinal obstruction remains one of the leading surgical emergencies worldwide, and the subset small bowel obstruction is the most commonly encountered surgical disorder of the small intestine . StudiesDiagnosis of ileoileal knotting is done intraoperatively. The exact cause remains unknown, but there are few stated hypotheses. Among them is the type of diet the patient consumes, that is, high fiber, which could also be the case in our setup . The morAfter intraoperative diagnosis, management is based on the viability of the bowel. When the bowel loops are viable, careful untying of the loops is performed as there is very low risk of recurrence. In the case of gangrenous changes, standard of treatment is controlled enterotomy decompression followed by resection and primary anastomosis guided by the length of ileum left after resection . In situPresentation of ileoileal knotting is not significantly different from high intestinal obstructions, but the high morbidity and mortality as a result of rapid progression into gangrene warrant a high index of suspicion. The diagnostic difficulty noticed in our case was due to the presentation overlap with gynecologic emergencies, especially in a woman of reproductive age. Since our patient presented with abdominal cramping and vomiting, factors such as sex of the patient, ultrasound showing fluid in the peritoneal cavity and cul-de-sac, and diagnostic paracentesis revealing blood should not have ruled out the diagnosis of intestinal obstruction before exploration. This indicates the need for a broader perspective, particularly in such patients.This second report of ileoileal knotting in Ethiopia should serve as a reminder of the possibility of the diagnosis, and to highlight the importance of early diagnosis and timely intervention to prevent unacceptable morbidity and mortality associated with this disease.


A myriad of pathologies can cause abdominal pain. Genitourinary causesincluding testicular torsion must be considered.In this report, we present a 17-year-old male evaluated in the emergencydepartment for lower abdominal pain. After physical exam, computedtomography, and ultrasound were completed, torsion of undescended testiclewithin the inguinal canal was diagnosed. Surgical exploration revealed atwisted, ischemic testis, and subsequent orchiectomy was performed.This case highlights the importance of a thorough genitourinary exam inpatients with lower abdominal pain. Representing approximately 8% of all visits, abdominal pain is the mostcommon complaint encountered in the emergency department (ED).A healthy 17-year-old male presented to the ED with left lower-quadrant abdominalpain. The patient experienced onset of severe pain upon awakening two days earlierwith associated nausea and vomiting. The pain had persisted although vomiting hadsince resolved. He had a history of constipation but recently had normal bowelmovements. He denied hematuria, dysuria, fever, or any other symptoms. Vital signswere normal. On physical exam, he had a firm, non-reducible mass in the leftinguinal region with tenderness and guarding to the left lower quadrant. Testicularexam was not performed initially.Laboratory studies including urinalysis were unremarkable. Computed tomography of theabdomen and pelvis was obtained, which revealed an undescended testicle in the leftinguinal canal with adjacent edema, as seen in The patient was reassessed, and testicular exam was performed revealing a normalright testis and empty left hemiscrotum. At this point, the patient and his motherconfirmed history of undescended left testicle. Testicular Doppler ultrasoundrevealed a hypoechoic testicle with absence of blood in the left inguinal canal, asseen in Urology was consulted and promptly took the patient to the operating room. The leftundescended testis was found to be nonviable with 720 degrees of torsion of thespermatic cord. A left orchiectomy and prophylactic right orchiopexy wereperformed.≤18.5Testicular torsion is a urologic emergency with annual incidence less than0.004% for males Cryptorchidism, or undescended testis, affects 2–4% of full-termmales with higher incidence seen in preterm infants.9What do we already know about this clinical entity?Testicular torsion is a relatively uncommon phenomenon that typicallypresents with scrotal pain. Torsion must be promptly identified andsurgically managed within six hours.What makes this presentation of disease reportable?Torsion of a cryptorchid testis is exceedingly rare and presentsdifferently than torsion of descended testis, often with lower abdominalpain.What is the major learning point?A high index of suspicion is necessary to make this diagnosis, as theetiology of undifferentiated lower abdominal pain is vast.How might this improve emergency medicine practice?A thorough genitourinary exam in patients presenting with lower abdominalpain will aid in diagnosis and improve patient care.The clinical presentation of undescended testicular torsion includes lower abdominalpain, vomiting, and decreased oral intake. Physical examination typically revealsinguinal swelling with a firm, tender mass and empty ipsilateral hemiscrotum.9Torsion of a cryptorchid testicle is an uncommon phenomenon that clinicians should beaware of and must include in their differential for abdominal pain. Torsion is oneof the few urologic emergencies. A high index of suspicion is required to make thisdiagnosis as it may imitate other acute abdominal emergencies including incarceratedinguinal hernia. Lower abdominal pain should always prompt consideration ofgenitourinary pathology. A thorough physical examination of the genitourinary tractshould decrease diagnostic error and improve patient care in such cases.