Radicular cysts are the most common cystic lesions that affect the jaws, which, though mostly asymptomatic, can be seen radiographically as an oval or pear-shaped unilocular radiolucency in the periapical region. Nonsurgical root canal procedures and periapical surgery followed by placement of bone substitute and bioceramic root-end filling material is generally the treatment of choice. This case report highlights the endosurgical management of long-standing trauma that led to a radicular cyst with respect to three maxillary anterior teeth in a young adult. The clinical and radiographic examination led to a provisional diagnosis of a radicular cyst, which was confirmed by biopsy. Non-surgical root canal treatment was performed with Mineral Trioxide Aggregate (MTA) as the apical barrier and surgical enucleation of the cyst was performed followed by placement of hydroxyapatite bone graft. Follow-ups till two years were done, which revealed the successful management of the case. A common consequence of long-standing tooth decay or injury is the radicular cyst, which originates from Malassez's cell rests . The priSmall-sized periapical granulomas can often be managed conservatively through non-surgical endodontic procedures, which serve as the primary approach for addressing these conditions . Oztan MThis case report presents a large radicular cyst involving three maxillary anterior teeth, i.e., teeth #21, #22, and #23 with tooth #22 having an open apex. Advanced radiological methods like Cone Beam Computed Tomography (CBCT) and histopathological investigation like biopsy, along with bioceramic restorative materials and bone grafts, contributed to successful endosurgical management of the case.A 19-year-old female patient presented at the Department of Conservative Dentistry and Endodontics with the primary concern of experiencing pain, swelling, and the discharge of pus in the upper left anterior area of her mouth for a duration of 4 months. She revealed a past incident of trauma that occurred 11 years ago.2 with obliterated nasolabial fold. On intraoral examination, a swelling on the labial vestibular region was appreciated. A heat vitality test was performed using a hot gutta-percha (GP) stick and electric pulp tester, which showed no response in these teeth. Radiological examination showed large periapical radiolucency in relation to teeth #21, #22, and #23  CBCT using Orthophos SL  at a resolution of 80 µm to determine the extent of the lesion. The images revealed maxillary teeth #21, #22, and #23 having a single well-defined intra-bony periapical radiolucency measuring approximately 19-20 mm mesiodistally, 17.5mm supero-inferiorly, 13-14 mm bucco-palatally with distinct sclerotic border. Bucco-palatal extension of the lesion caused remarkable expansion and thinning of the palatal cortex followed by a breach in the palatal and buccal cortical plates. Patient history, and clinical and radiographic examinations led to a provisional diagnosis of infected radicular cyst.The patient was explained about the condition, and the treatment plan was discussed. After obtaining informed consent, non-surgical endodontic treatment was initiated. An 18-gauge syringe was used to aspirate the cystic contents. The enucleated lining was transported in 10% formalin in an air-tight container for histological examination. Splinting was done using a fibre splint on the labial aspect from tooth #13 to #24 followed by access opening and biomechanical preparation. Due to continuous pus drainage through the root canal, the patient was to wait for some time. Once the pus drainage was reduced, a closed dressing was given with two small cotton balls in the access cavity sealed with triple antibiotic paste (temporary restoration). Oral antibiotics  were prescribed at a dosage of thrice daily for five days along with a combination of non-steroidal anti-inflammatory drugs (NSAID) (aceclofenac 100mg with serratiopeptidase 15mg and paracetamol 325mg) was given for twice daily for five days. The patient went through a complete oral prophylactic procedure before the next visit.The patient was recalled after 48 hours to review the clinical condition. Temporary restoration was removed and the canals were irrigated using normal saline. Then the canals were dried using sterile paper points and a closed dressing with triple antibiotic paste was given. The patient was recalled after two weeks for obturation and periapical surgery.During the subsequent appointment, the interim restoration was taken out, and the canals were flushed with chlorhexidine (CHX) 2% as a cleansing solution. Tooth #22 was carefully dried, and a 3mm apical barrier made of Mineral Trioxide Aggregate (MTA) was placed at the root tip using an MTA carrier. The filling of the root canal was accomplished using thermoplasticized gutta-percha and the patient was prepped for the surgical procedure. For local anaesthesia, the infraorbital and nasopalatine nerve areas were numbed with a mixture of lignocaine and adrenaline at a ratio of 1:80,000. A complete mucoperiosteal flap was raised, extending from tooth #21 to #23. Upon elevating the flap, the cystic formation was clearly visible at the apex of tooth #22, along with a gap along the root's length. To excise the cyst, wet gauze was employed to create a separation between the cyst and the surrounding bone. With the utilization of our utmost surgical skill and expertise, the cyst was fully extracted and preserved in formalin for subsequent analyses  within the periodontal ligament . It commIn such cases, surgical intervention followed by the application of suitable bone graft material is the preferred treatment approach . A signiIn the present case, MTA was employed as the retrograde filling substance. The selection of an ideal root canal filling material (thermoplastic GP) has a substantial impact on the surgical outcome. An optimal material should possess qualities such as non-absorbency, non-corrosiveness, non-cytotoxicity, resistance to moisture, dimensional stability, biocompatibility, antibacterial properties, radiopacity, cost-effectiveness, ease of manipulation, adhesion to dentinal walls, the establishment of a secure seal, and the initiation of cementogenesis ,12.Staphylococcus epidermidis bacteria [In a study by Torabinejad et al. (1995), MTA demonstrated the prevention of apical leakage of introduced bacteria . Moreovebacteria .The process of bone regeneration following periapical surgery hinges on crucial factors such as primary wound closure, angiogenesis for blood supply, a source of undifferentiated mesenchymal cells, maintaining space, and ensuring wound stability (referred to as the PASS principle). The integration of bone grafts represents the most prevalent regeneration technique . OsteocoThis case report illustrates the successful management of a complex radicular cyst involving multiple maxillary anterior teeth. It emphasizes the critical role of a multidisciplinary approach, advanced diagnostics, precise surgical and non-surgical interventions, and the strategic use of materials like MTA and hydroxyapatite bone graft. This case highlights the challenges in treating such cysts and stresses the importance of collaborative efforts among dental specialists. Long-term follow-up confirms treatment effectiveness, emphasizing the need for ongoing monitoring to assess healing and stability over time.


Parathyroid adenomas are benign proliferative disorders of parathyroid glands. Patients typically exhibit hyperparathyroidism and elevated serum calcium levels due to elevated levels of parathyroid hormone (PTH). We report a newly diagnosed case of a rare pathological osteolytic lesion. Radiological evaluation revealed multiple bony lesions in multiple parts of the pelvis, vertebral body, and spinous process, suggesting hematological neoplasms or bone marrow metastatic carcinoma. The morphology revealed many abnormal cells in the bone marrow smear. Furthermore, serum calcium and PTH levels were significantly increased compared to normal levels. Doppler color ultrasound showed a thyroid mass (left), suspected parathyroid adenoma, thyroid, and isthmus nodular goiter (right). The patient underwent bilateral neck exploration with parathyroidectomy, and serum calcium and PTH levels significantly decreased on the second day after surgery and had a surgical cure. Parathyroid adenoma is a type of parathyroid proliferative disease, including parathyroid hyperplasia, parathyroid adenoma, and parathyroid cancer. Eighty to 85% of patients with parathyroid adenomas typically exhibit hyperparathyroidism . HyperpaA 42-year-old woman complained of general weakness for one week and had a history of fracture. Physical examination revealed no other special findings, except for bone pain. Complete Blood Count displayed small cell hypopigmentation anemia, and serum iron 3.60 μmol/L , unsaturated iron binding force 65.63 μmol/L . Accordingly, this patient was supposed to be diagnosed as iron deficiency anemia (IDA). However, computed tomography (CT) showed multiple low-density shadows in the L3 vertebral body, sacrum, pubis, ischium, and both femurs. Positron emission tomography-computed tomography (PET-CT) also showed elevated metabolism in the pelvis, suspected hematological neoplasms, and bone marrow metastatic carcinoma Figure 3The parathyroid gland produces parathyroid hormone (PTH), which plays a key role in regulating the calcium balance in the body . ParathyThis patient started with fatigue, and CT imaging showed low-density shadows of multiple parts of the body. MRI showed bone destruction of the L3 vertebral body and spinous process, and PET/CT fusion image showed bone destruction of the bilateral ilium with abnormal metabolism. Osteolytic lesions are common imaging changes in multiple myeloma and bone metastatic carcinomas , 6. HoweHowever, Doppler color ultrasound revealed a thyroid mass, thyroid, and isthmus nodular goiter, while serum calcium and PTH levels were significantly increased. Based on these results, the patient was clinically diagnosed with parathyroid adenoma. Therefore, the parathyroid adenoma, thyroid, and isthmus goiter were removed under general anesthesia. Based on the histopathology and clinical context, the tumor was identified as a parathyroid adenoma. The serum calcium and PTH levels also decreased significantly after parathyroidectomy.Parathyroid adenoma is a benign tumor of the parathyroid gland that involves a single gland and is usually the main cause of primary hyperparathyroidism 80%), followed by parathyroid hyperplasia (15%), ectopic parathyroid adenoma (4%), and multiple parathyroid adenomas (1–2%) . In the 0%, folloParathyroid adenomas mainly occur in female aged 40–80 years , 10. IncCurrently, parathyroidectomy is the best choice for hyperparathyroidism to reduce the long-term destructive effect on bone and the negative effect of high serum calcium levels . PreventThis is an extremely rare and easily misdiagnosed severe osteolytic lesion caused by parathyroid adenoma. This report contributes to improving the awareness of clinicians and pathologists that the clinical, radiologic, and cytomorphological suspicion of hematological neoplasms or metastatic carcinoma may also be benign tumors. Clinicians and pathologists must keep in mind that parathyroid adenomas can cause osteolytic lesions and increase the number of osteoclasts, especially in hyperparathyroidism.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Written informed consent was obtained from the participant/patient(s) for the publication of this case report.JC collected clinical data. GT and YP diagnosed and followed up the patient. HC reviewed the literature and prepared the initial draft of the manuscript. All authors contributed to the article and approved the submitted version.


Biliary fistula is a rare (less than 8%) cholecystectomy complication, internal fistulae being the most common of them . However, the presence of two fistulas at the same time is extremely rare, with a small number of cases reported in the literature to date. Symptoms tend to be non-specific, leading to a difficult preoperative diagnosis. The standard treatment for bilioenteric fistulas is open cholecystectomy and subsequent closure of the fistula. Nonetheless, modern techniques including laparoscopic and endoscopic approaches have been reported lately for their treatment with favorable results. We present a case of concomitant cholecystoduodenal and cholecystocolic fistula successfully treated with subtotal cholecystectomy and primary closure of the fistulous tracts by laparoscopic approach in a female Hispanic patient. A biliary fistula consists of communication or an abnormal passage from the biliary system to an organ, cavity, or skin. These are classified as internal  or external (biliary-cutaneous) . BilioenThis article reports a rare case of cholecystoduodenal and cholecystocolic fistula successfully treated with subtotal cholecystectomy and primary closures of both fistulas by laparoscopic approach.A 50-year-old Hispanic female patient with a medical history of diabetes mellitus type II and hypertension presented to the general surgery outpatient clinic with a two-month history of recurrent abdominal pain in the right quadrant, exacerbated by copious meal intake. Nausea, vomiting, average bowel movement frequency change, fever, jaundice, or hematemesis were denied. Physical examination was negative for Murphy’s sign and rebound tenderness. Laboratory workup revealed: white blood cell count 7.36 x 109/L, hemoglobin 12.9 g/dL, aspartate aminotransferase (AST) 18.3 U/L, alanine transaminase (ALT) 16 U/L, alkaline phosphatase 52 U/L, total bilirubin 0.3 mg/dL, and direct bilirubin 0.14 mg/dL. Upon upper abdominal ultrasound, liver and intrahepatic duct were identified without any abnormal findings; gall bladder was identified revealing dense posterior acoustic shadowing and thickness of the wall (3 mm). The common bile duct was normal, measuring 4 mm in diameter. Elective surgery with laparoscopic cholecystectomy was decided. Intraoperative findings revealed a gallbladder adhered to the surrounding omentum and transverse colon, with a fistulous communication of the fundus to the transverse colon Figure .Gallbladder and transverse colon were dissected, and the fistula was excised. The remaining defect of the colon was repaired using a continuous absorbable suture and a non-absorbable suture as a second layer. After gallbladder mobilization, a second fistula was found between Hartmann’s Pouch and the second part of the duodenum Figure ,B. The fThe postoperative period was uneventful, with an average serohematic drainage of 10-15 cc per day. Methylene blue leak test was performed on postoperative day five with a negative result, thus oral diet was initialized. On postoperative day seven, the patient was discharged due to an adequate evolution. Drainage was removed after one week, and after one-month laboratory workup and histopathology reports were normal without any evidence of malignancy. Cholelithiasis is one of the most frequent pathologies worldwide, accounting for approximately 20 million people, from which 1.8 million present a condition that requires surgery. Cholecystectomy is the most common elective abdominal surgery, with an estimated of 750,000 surgeries performed every year . CholecyThe standard treatment of a bilioenteric fistula is open cholecystectomy and closure of the fistula . Given tSome other treatment options recently reported for the closure of both fistulas  include metal stent on the colon, and polyglycolic acid sheets in the duodenum by endoscopic closure . PatientTo the best of our knowledge, this is the first case of cholecystoduodenal and cholecystocolic fistulae reported in our country treated successfully by laparoscopic approach.Bilioenteric fistulas are a rare presentation of biliary pathology. Treatment of choice is conventional surgery, nonetheless, with the increasing availability of modern techniques such as laparoscopy, this can become an option. Subtotal cholecystectomy plus primary closure of the fistula tract may be an option in complicated cases. More studies are needed to further assess this technique’s effectiveness in treating gallbladder double fistula.


Clinical problem solving evolves in parallel with advances in technology and discoveries in the medical field. However, it always reverts to basic cognitive processes involved in critical thinking, such as hypothetical–deductive reasoning, pattern recognition, and compilation models. When dealing with cases of acute abdominal pain, clinicians should employ all available tools that allow them to rapidly refine their analysis for a definitive diagnosis. Therefore, we propose a standardized method for the quick assessment of abdominopelvic computed tomography as a supplement to the traditional clinical reasoning process. This narrative review explores the cognitive basis of errors in reading imaging. It explains the practical use of attenuation values, contrast phases, and windowing for non-radiologists and details a multistep protocol for finding radiological cues during CT reading and interpretation. This systematic approach describes the salient features and technical tools needed to ascertain the causality between clinical patterns and abdominopelvic changes visible on CT scans from a surgeon’s perspective. It comprises 16 sections that should be read successively and that cover the entire abdominopelvic region. Each section details specific radiological signs and provides clear explanations for targeted searches, as well as anatomical and technical hints. Reliance on imaging in clinical problem solving does not make a decision dichotomous nor does it guarantee success in diagnostic endeavors. However, it contributes exact information for supporting the clinical assessments even in the most subtle and intricate conditions. When imA few decades ago, Eddy and Clanton  proposedThe clinician gathers elementary cues, such as clinical signs, the history of the disease, test results, etc., into blocks of information that allegedly share a common physiopathological background. This aggregate of cues forms the Pivot, which has the role of reducing the complexity of the clinical problem. A list of differential diagnoses is then developed. These are compatible with the Pivot but are matched with all of the findings of the case, one by one, during Pruning. When more diagnoses match the Pivot and the available case data, additional tests or cues are sought until a definitive unique diagnosis is selected. Finally, this is validated against all of the findings of the case. Pattern recognition is vital during the development of the Pivot, and deductions are necessary to develop hypotheses during the ensuing steps of the CPS process.However, when clinicians recognize a typical pattern, they might fall for the mirage of the first lesion, unwisely skipping the Pruning, Selection, and Validation, and increasing the risk of advancing an incorrect diagnosis.If a Pivot cannot be established, the natural course of action will be the formulation of a hypothesis by employing basic pathological mechanisms and deductions. In this review, we focus on searching for patterns when reading abdominopelvic CTs, radiological cues, and technical modifications of radiological examinations to enhance their accuracy and their relevance in achieving rapid and correct diagnosis in cases of acute undifferentiated abdominal pain.Multiple-target visual search is the mainstay of abdominopelvic CT interpretation. Unfortunately, it is affected by a phenomenon that was described by Smith et al.  almost sIn a recent paper by Kliever et al. , the autThe influence of clinical information on reporting was demonstrated in a prospective blinded study that analyzed the results written before and after clinical input. Inconsistent clinical details have a detrimental effect, while accurate information improves the quality of a report ,16,17,18A prospective study by Parag et al.  demonstrAcute abdominal pain accounts for up to 10% of all presentations at emergency departments ,22. ManyThe role of a holistic first look is advocated by numerous authors who claim that by glancing over the scan, the brain can recognize patterns by employing neural network pathways based on the concepts of proximity, similarity, continuity, closure, and grouping ,26,27,28The human eye is incapable of discerning discrete increments in tonal intensity, unlike computers . TherefoContrast-enhanced CT implies the acquisition of images after the administration of oral or/and IV contrast. Although the administration of oral contrast is debatable, and no consensus on its use has been reached, IV contrast is recommended for most abdominopelvic acute conditions ,32,33. WWe grouped these instruments for image modulation under the practical name of “the ABC of lesion enhancements”, and we believe that, together with anatomical concepts and the use of clinical patterns, these form a triad for the correct interpretation of CT images by non-radiologists. Clinicians use a mental catalog of normal and abnormal findings when searching for lesions; hence, the following 16 steps should be approached in order during interpretation .Over recent decades, CPS in the acute abdomen has shifted from a purely clinical undertaking to an intricate and multidisciplinary process . The uniAcute appendicitis (AA) carries a lifetime risk of up to 9% in Western countries but remains difficult to diagnose based only on clinical criteria . The AlvAcute pancreatitis is a potentially fatal condition with an increased incidence over the last 50 years ,45. Its Bowel obstruction is common and represents about 20% of admissions with acute abdominal pain in surgical departments . This isBiliary stones are highly prevalent, especially in Western populations, but almost 70% of the cases remain asymptomatic . AlthougRight upper abdominal pain, fever, vomiting, signs of peritoneal irritation, moderate leukocytosis, and ultrasonography findings are helpful but not specific, and they barely help to differentiate other pathologies that do not have indications for surgical treatment, such as hepatitis, peptic ulcer disease, pancreatitis, primary hepatic abscess, gastroenteritis, and urinary tract infection ,60,61,62In case of doubts regarding the diagnosis or the presence of complications, a CT scan can be performed, as this is considered the most sensitive investigation available in ED ,64. CT fReliance on imaging in CPS does not make a decision dichotomous nor does it guarantee success in diagnostic endeavors. However, it contributes exact information to support clinical investigations for even the most subtle and intricate conditions. A borderline Alvarado score might be in favor of surgery due to a tiny amount of fat stranding around the caecum. Similarly, but on a bolder note, multiple distended bowel loops showing air–fluid levels could point towards a narcotic bowel rather than a mechanical obstruction in a young addict with uniformly ubiquitous distension and no transition point. We believe that in times of increased need for urgent clinical decisions, all practicians should be equipped with CT interpretation skills. A standardized approach to charting a rigorous and systematic search pattern, accompanied by sound clinical reasoning, is the modern prerequisite for a safer practice.


Myeloid sarcoma is rare and nasal chloroma is an uncommon initial manifestation of acute myeloid leukaemia. The correct diagnosis is a big challenge. In this report, we present a case of myeloid sarcoma of the nasal cavity with extension to the soft tissues of the face. A 53-year-old woman with a past medical history of thalassemia, not followed up, presented with a progressive greyish swelling in her right cheek associated with a nasal obstruction more marked on the right side and unilateral lacrimation. The diagnosis of myeloid sarcoma was based on histopathology and immunohistochemistry. Bone marrow aspiration testing revealed blasts that met the criteria for acute leukaemia. She received external radiotherapy at a total dose of 30 Gy in 15 fractions without systemic therapy, because she refused to get chemotherapy. She remained under surveillance and symptomatic treatment. The patient was examined four months after the end of the irradiation and showed a spectacular improvement in her clinical symptomatology with a clear decrease in nasal mass. Myeloid sarcoma (MS), also called chloroma because of its green colour attributable to the enzyme myeloperoxidase, is defined by an extramedullary proliferation of blasts of one or more of the myeloid lineages , which iA 53-year-old woman with a medical history of thalassemia since 2006, not followed up, and a hysterectomy for uterine fibroids in 2010 presented in January 2022 with progressive greyish swelling in her right cheek, evolving for three months and associated with a nasal obstruction more marked on the right side and ipsilateral lacrimation . Peripheral smear examination showed 8% atypical cells, 15% polymorphonuclear neutrophils (PMN), 6% monocytes, and 71% lymphocytes. Bone marrow aspiration showed a cellular marrow with 75% blasts with diminished erythropoiesis and megakaryopoiesis. On immunophenotyping by flow cytometry of bone marrow, the blasts expressed MPO, CD117, and CD33, without expression of markers of immaturity or lymphoid antigens.A computed tomography (CT) of the face reported an intranasal mass obstructing the external nares with extension to the right cheek without bone destruction. It bulged in the nasopharynx posteriorly, extended to the ethmoidal cells superiorly, and was associated with a right lateral cervical lymphadenopathy of 16 mm. A biopsy of the mass was done which showed a large number of atypical cells that were small to medium in size, with high nucleo-cytoplasmic ratio, prominent nucleoli and hyperchromatic nucleus. On immunohistochemistry, the cells expressed positivity for anti-vimentin and anti-myeloperoxidase (MPO) and were negative for CD45, CD3, CD20, CD30, creatine kinase (CK), CD 138, CD79a, CD56, P63, Synaptophysin, chromogranin, glial fibrillary acidic protein (GFAP), myogenin, Melan A, CD99, and terminal deoxynucleotidyl transferase (TdT). Thus, a diagnosis of MS was made. Complete blood count revealed pancytopenia (haemoglobin 7.1 g/dl, total leucocyte count 1780/mmThe patient was diagnosed with AML presenting as MS. External radiotherapy was then decided for the facial mass while including the skin. She was planned for a total dose of 30 Gray in 15 fractions Figure , at a daThe follow-up after four months showed a dramatic improvement with the disappearance of the initial swelling, as well as an improvement in nasal obstruction Figure .AML is the result of malignant clonal expansion and differentiation arrest of immature myeloid progenitors . In addiWe described a case of MS presenting as a nasal cavity mass with extension to the soft tissues of the right cheek in a 53-year-old female. In about a quarter of cases, MS is the initial sign of AML; it may precede it by months or even years. In 15-35% of cases, MS develops at the same time as AML, and in up to 50% of cases, it develops after the diagnosis of AML. It may also be the first sign of relapse in a patient who was previously treated for AML and who is still in remission . In the Historically, nearly 75% of MS cases have been misdiagnosed. With recent improvements in diagnostic techniques, this has improved; however, 25-47% of instances still result in a misdiagnosis . ImagingConcerning treatment strategies, a universal agreement has not yet been established with regard to therapeutic alternatives because of the rarity of the disease and the diversity of body sites and age groups ,8. The eMS is an extramedullary event of AML and can sometimes be the only sign of the disease. It is rarely seen in the nasal cavity. Due to its unusual presentation, the correct diagnosis is difficult. Because of the disease's rarity and lack of randomized controlled studies, there is no consensus on the treatment of MS. Radiation therapy appears to provide local control of chloromas with low doses, which is the case for our patient, but it is not sufficient and must be associated with systemic therapy.


We present a case of a child who was transported to the Neurosurgery Clinic from another hospital for the purpose of performing a surgical procedure of the spinal myelomeningocele. On the first day of the stay, a set of tests was performed, including an anterior-posterior (AP) projection X-ray, which clearly showed a developmental defect in the lumbar-sacral section of the spine. In the follow-up physical examination, there was a depression of the skin on the right side of the surgical scar after closing the open myelomeningocele. In the follow-up MRI of the lumbar-sacral section, an extremely rare congenital anterior dislocation of the sacrococcygeal bone was unexpectedly visualized. Despite recommendations for further diagnostics, the patient did not attend the required follow-up examinations. In the final section, we provide a general summary of the literature on rare developmental defects of the spine in children. A female newborn was delivered via cesarean section  with a diagnosed lumbar myelomeningocele and significant lower limb deformities after birth. The child was transported to our institute for further treatment. According to the medical record, the initial prenatal ultrasound was normal. In the 30th week of pregnancy, intrauterine growth restriction (IUGR) was diagnosed, and on the day of delivery, oligohydramnios and ventricular system enlargement of the central nervous system (CNS) were detected. On the first day of the patient’s stay, a set of tests was performed, including an anterior-posterior (AP) projection X-ray. The study shows a developmental defect of the lumbar-sacral spine .The child was qualified for a hernia repair surgery. A medical rehabilitation specialist diagnosed the lower limbs positioned in flexion and adduction at the hip joints (trace movement), extended in the knee joints (trace flexion—more frequently in hyperextension), and feet in a stable equinovarus position. The patient’s CT scan confirmed ventriculomegaly without evident signs of active hydrocephalus. Ultrasound examination did not reveal any residual urine in the bladder after voiding. In the follow-up physical examination, there was a depression of the skin on the right side of the surgical scar after closing the open myelomeningocele. An MRI examination was performed to exclude the presence of a dermal sinus, which revealed a developmental defect of the sacrococcygeal bone . DespiteIn this study, we present what we believe to be an extremely rare developmental defect of the lumbar-sacral spine. Although the parents did not continue the therapeutic procedure despite the recommendations, further stages such as control medical visits for the purpose of assessing the clinical neurological state and development of the child are crucial in such complex pathologies. In addition, control radiological examinations, MRI, X-ray, CT, or others, depending on the clinical and neurological condition of the patient, would allow for an assessment of the behavior and dynamics of the defect. We must not forget that the child underwent surgical treatment for a spinal myelomeningocele. Control tests for the evaluation of the structures of the spinal canal and CNS are essential. Surgical procedures are exceptionally difficult to assess, due to the uniqueness of the defect, and further multi-specialist care is highly recommended.Congenital defects of the sacrococcygeal segment in infants pose a significant medical challenge and are often diagnosed at the prenatal stage thanks to imaging techniques such as ultrasonography . VariousLumbosacrococcygeal agenesis is a rare developmental defect in which part or all of the lumbar, sacral, and coccygeal vertebrae are missing. This defect is usually associated with multiple other internal organ defects and syndromes, such as Currarino syndrome. Treatment is complex and typically requires a multidisciplinary approach .Caudal regression syndrome is a rare developmental defect characterized by the incomplete development of the lower part of the spine. This defect can affect the function of pelvic organs, including the bladder and intestines, and it can also lead to varying degrees of dysfunction and deformation of the lower limbs. It is often associated with maternal diabetes .Anterior angulation of the coccyx is an anomaly in which the coccyx bone is bent or deviated forward. This can lead to discomfort and pain, especially when sitting. Causes of this condition may include trauma, childbirth, or congenital anomalies. Treatment is usually conservative, although surgery may be considered in extreme cases .Myelomeningocele is another serious defect that involves the presence of an open hernia in the spinal area, through which the meninges and spinal cord are visible. This results in damage to the nervous system, leading to various neurological complications, such as paralysis of the lower limbs .An important aspect of treating these defects is a comprehensive approach that includes both medical and psychological aspects. Although advancements in research on congenital sacrococcygeal segment defects are promising, there are still many challenges. Preventing sacrococcygeal segment developmental defects is also an area of active research. Many of these defects may be associated with environmental factors, such as exposure to certain chemicals during pregnancy. Folic acid supplementation is one proven way to prevent many spinal developmental defects .In summary, congenital defects of the sacrococcygeal segment are a serious medical challenge that requires an integrated approach that includes early defect detection, effective treatment methods, and support for families. Achievements in research on these defects are promising, but there is still much to understand in order to provide better outcomes for patients affected by these conditions.


Obturator hernia is a rare condition that is difficult to detect clinically. We highlight the importance of a CT scan in establishing an early diagnosis of an obturator hernia, effective surgical intervention planning, thereby enhancing the result.  It was associated with constipation and numerous bouts of vomiting. She has been a smoker since she was 15 years old, averaging 5–10 cigarettes per day. She has a medical history of chronic obstructive pulmonary disease and has been taking medication for 7 months with poor compliance. She had a history of hemorrhoidectomy surgery around 2 years ago. She has given birth eight times, with two abortions. On examination, her heart rate was 122 beats per minute, and her blood pressure was 110/80 mmHg. The abdomen was soft and tender in the lower left quadrant, with no guarding or rigidity. Femoral and inguinal hernias were not detectable on palpation. On chest auscultation, both sides had decreased air entry.3Blood tests were performed and found to be within normal limits. Ultrasonography revealed features of small bowel obstruction and ascites. Her CT scan demonstrated a loop of small bowel  herniating through the left obturator foramen between the left pectineus and obturator externus muscles Figures  and 2. F4She had an emergency laparotomy, which revealed wide open left obturator foramen Figure  with her5Following repair of her obturator hernia, the patient's presenting symptoms resolved.Postoperatively, she was hospitalized in the intensive care unit (ICU) for 4 days due to oxygen requirement. On day 1, 300 cc of a bluish‐green fluid was drained from her nasogastric tube. Her nasogastric tube was taken out on day 3. On day 4, she moved to the surgical ward, where she spent the next 5 days. Multidisciplinary efforts of the surgical, medical, and physiotherapy teams produced quick results.6The protrusion of abdominal viscera through the obturator canal is known as an obturator hernia. The obturator nerve and vessels are located inside this 2–3 cm long and 1 cm broad structure, which is bordered inferiorly and laterally by the obturator membrane and superiorly and laterally by the pubic bone.Because the signs and symptoms are frequently non‐specific, it is estimated that only 20%–30% of obturator hernia patients receive a correct preoperative diagnosis.Obturator hernia has three stages. The first stage includes the entry of preperitoneal tissue into the pelvic opening of the obturator canal, whereas the second stage involves the formation of a dimple in the peritoneum and leads to the formation of a peritoneal sac overlaying the canal. During the third stage symptoms are caused by the herniation of the viscera into this sac.Actually, emergency multidetector CT scanning could result in more rapid diagnosis and earlier surgical intervention, improving the outcome. Meziane et al. reported the first use of a CT scan to detect obturator hernia in 1983.Obturator hernia can only be treated surgically. In an emergency, an abdominal approach through a low midline incision is preferred. Because of gangrene or perforation, resection of the involved portion of bowel is sometimes required.7An obturator hernia is very rare and difficult to diagnose with a high rate of morbidity and mortality. This type of hernia must be considered in elderly and chronically ill women with signs of bowel obstruction. Abdominal CT scan is the best diagnosis tool. Early CT should be taken into consideration in situations of intestinal obstruction in order to speed up the diagnosis and, as a result, reduce consequences such as bowel ischemia and the requirement for bowel resection during surgery.This patient was properly informed for her clinical information to be included in this publication. Written consent was obtained from her grand‐daughter as the patient herself could not read or write.Manisha Aryal: Investigation; supervision; writing – review and editing. Suraj Keshari: Investigation; writing – original draft; writing – review and editing. Archana Pandey: Writing – original draft; writing – review and editing. Abhishek Pandey: Writing – review and editing. Ishwor Paudel: Writing – review and editing.All authors declare that there is no conflict of interest regarding the publication of the article.None.


Inflammatory polyps, also known as pseudo-polyps, are a common benign condition affecting 10-20% of patients with inflammatory bowel disease. Chronic, repeated inflammation and ulceration associated with healing lead to the formation of polyp-like structures in the colon. Although there are no common symptoms accompanying these pseudo-polyps, they can present with anemia, weight loss, diarrhea, intussusception, palpable mass, abdominal pain, discomfort, and melena, not to mention bowel obstruction that happens infrequently. Finally, it is important to recognize giant inflammatory polyps as they may occasionally be mistaken for colon cancer, leading to unnecessary surgical interventions. We present the case of a 38-year-old woman who was diagnosed with ulcerative colitis 10 years back, treated with oral mesalamine for five years, and had no follow-up after this period. She came to our clinic complaining of recurrent obstructive symptoms for a few months. Examination shows tenderness in the left lower quadrant with normal vital signs and bowel sounds. Inflammatory polyps or pseudo-polyps are a well-known complication of inflammatory bowel disease. They develop in 10-20% of patients with the disease -5. RarelPseudo-polyps usually cause no symptoms and are discovered incidentally during colonoscopy. However, they may manifest clinically with various symptoms, including weight loss, melena, anemia, diarrhea, cramping abdominal pain, palpable mass, and intussusception. In very rare cases, they show obstructive symptoms -8.Their significance stems from the fact that, among these individuals with UC who are at higher risk for colonic malignancy, GIPs are frequently mistaken clinically and radiologically for carcinomas, potentially leading to unnecessary surgery.A 38-year-old woman was evaluated at our department with a 10-year history of UC. She was initially diagnosed with the disease based on symptoms and a colonoscopy with biopsies, which confirmed chronic ulcerative pancolitis. Thereafter, she was placed on oral mesalamine and remained in clinical remission for 5 years. However, she was lost to follow-up and has not been on treatment since. This time, she was seen and evaluated regarding obstructive symptoms including bloating, constipation, and lower abdominal pain associated with weight loss. These symptoms had been recurrent for a few months. At presentation, she was experiencing mild abdominal pain.On physical examination, the patient was afebrile (36.5◦C), and her abdomen was tender in the left lower quadrant with no palpable masses or signs of peritonitis. The bowel sounds were normal. Laboratory investigations showed mild microcytic hypochromic anemia , normal white blood cell counts, and mildly elevated C-reactive protein at 7 mg/dL. A colonoscopy was then performed as an outpatient, and quiescent pancolitis with a large near-obstructing mass approximately 5 cm in size at the descending colon was demonstrated Figures -1C. UsinAn abdominal computed tomography scan was then performed to evaluate any extramural extension of the lesion. The scan revealed a large semi-obstructive mass at the descending colon Figures -2B.Although biopsies suggested inflammatory polyps, a large mass underlying dysplastic and malignant alterations could not be ruled out. In most cases, most biopsies in a large mass can be superficial. For that reason, a multidisciplinary team, including a colorectal surgeon, discussed the case in detail regarding the best care for the patient. The recommended plan was shared with the patient, who agreed to undergo a total colectomy. She then underwent a total colectomy with ileorectal anastomosis, and her recovery was uneventful Figure . The patGIPs are associated with inflammatory bowel disease with chronic pancolitis. They are extremely rare and can result in large bowel obstruction. The first report was in 1965 when Dr. Goldgraber described a localized recurrent giant pseudo-polyposis [In the present case report, the patient had chronic ulcerative pancolitis for more than 10 years and was not on therapy for the last five years. Her symptoms were bloating, constipation, and weight loss associated with lower abdominal pain rather than acute flare, which usually is accompanied by diarrhea. Further evaluation revealed a large obstructing colonic mass in the form of a pseudo-polyp approximately 5 cm in size, which was managed with surgical resection.GPP typically presents with symptoms of inflammatory bowel disease flares, such as abdominal pain and diarrhea, but rarely presents with obstructive symptoms. In a systematic review by Maggs et al., 78 patients with GPP were studied. Of them, 15% had complications related to obstruction and sub-obstruction, and 3% had mechanical intussusception due to the GPP's large size . Ooi et al. showed that the median time from diagnosis to developing GIPs for UC and Crohn's disease is five and six years, respectively . In contPseudo-inflammatory polyps are an independent indicator of a higher risk of malignancy. Multivariate analysis revealed that PIPs are associated with a twofold increase in the risk of malignancy  and a four-fold increase in colonic strictures  when 68 cases of colorectal cancer complicating UC were compared with 136 matched controls [GIPs, however, are viewed as a benign phenomenon. Only one instance of occult carcinoma developing in a patient with localized GIP has been documented . Even ifDifferent modalities are used for the treatment of PPs, including medical, endoscopic, and surgical. Regression of PPs has been demonstrated when medical treatments such as mesalazine and azathioprine are utilized. For symptomatic PPs or PPs for which endoscopic criteria alone were unable to exclude malignancy, endoscopic resection with electrocautery is used. Surgical management is reserved for PPs complicated by obstruction or intussusception -16.Most of these cases were managed surgically and only a few cases were treated medically and resulted in regression of the polyp -13,17. TWe report a rare case of giant inflammatory polyposis in long-standing UC presenting with obstructive symptoms mimicking malignancy. A step-up approach with aggressive medical therapy targeting mucosal healing with continuous surveillance would likely prevent these complications.


Schwannomas are tumors of the nerve sheath that consist of Schwann cells that are often described as slow-growing. Glossopharyngeal schwannomas are rare tumors present in the region of the posterior fossa, with limited case reports present in literature. While patients may present asymptomatically, some present with vestibulocochlear symptoms or lower cranial nerve dysfunction.We report an extremely rare case of a left para-pharyngeal carotid space glossopharyngeal schwannoma in a 26-year-old female. The presentation was a 3-month left sided neck swelling and a hoarse voice. Radiological investigations were completed . Investigations revealed a solid lesion measuring about 29 × 10 mm. The final decision was to excise the mass under microsurgery.CN 9–11 schwannomas are often called jugular foramen schwannomas. Intraoperatively, these get differentiated as glossopharyngeal schwannomas. Diagnosis involves a physical examination, a detailed history, audiological assessments, and radiological investigations. While MRI scans are known as the most effective pre-operative diagnostic test, cases are in majority discovered intra-operatively. Surgical excision is the recommended approach. Post-operative recurrence is rare. Pre-operative diagnosis is often difficult due to the rarity and similarly presenting differential diagnoses.Schwannomas of the glossopharyngeal nerve are extremely rare tumors that may present with lower cranial nerve or vestibulocochlear deficits. Magnetic resonance imaging is a useful tool in diagnosing this unordinary tumor. This case report intends to provide further data regarding the clinical presentation, the patient population, and the diagnostic and surgical approach in dealing with this incredibly rare tumor. •Schwannomas are encapsulated, benign tumors of the nerve sheath originating from Schwann cells.•The symptoms of glossopharyngeal schwannoma are non-specific, until the tumor gets a fairly large size.•The diagnosis of glossopharyngeal schwannoma is confirmed intraoperatively. These cells form an insulating layer around the peripheral nerves, representing approximately 7 % to 10 % of all primary intracranial tumors .Schwannomas can grow on both peripheral nerves and nerve roots; with a notable example being vestibular schwannomas and jugular foramen schwannomas. These originate from the ninth, tenth, and eleventh cranial nerves ,4. AmongThe objective of this case report intends to provide further literature on this incredibly rare tumor and to demonstrate yet another example of how a patient may present, alongside demonstrating the steps taken to adequately manage the case. This case report brings up one of the only reported glossopharyngeal schwannomas found in the Middle East. This work has been reported in line with the SCARE 2020 criteria .2A 26-year-old female presented in June 2021 with a three-month history of a left sided neck mass. The patient described her presentation as a fullness in her throat. Later, she noticed a painful left sided neck mass associated with hoarseness of voice. This mass had grown to approximately 2 cm in size when she had first sought to seek medical attention. The patient denied any history of snoring, dysphagia, odenophagia, fever, or weight loss. There were no neurological or otological symptoms.The patient was previously healthy with no past medical history. She underwent previous surgeries including a sleeve gastrectomy, abdominoplasty, and a laparoscopic cholecystectomy. She is non-married and has been a smoker for 10 pack years. She has no history of any drug allergies and has no family history of the same complaint of any genetic or immunological disorders. It is to be noted that patient comes from a middle-class background.On examination, the patient was healthy looking, conscious, alert and oriented to time, place and person. Her vitals were unremarkable and she was afebrile. Examination of the nose, throat, paranasal sinuses, and tympanic membranes were normal. Tuning fork tests (Rinne and weber tests) were normal. No spontaneous nystagmus was noted. Her neurological examination was normal and her cranial nerves were intact. Examination of her neck showed a tender left sided neck mass, anterior to the sternocleidomastoid muscle, of 2 × 2 cm in size, firm, with normal skin above it. There were no enlarged cervical lymph nodes. Her full blood count, urea and electrolytes, fasting blood sugar, cholesterol, and triglycerides, were all within normal limits.Ultrasound of the neck was done that showed a well-defined oval shaped lesion seen just posterior to the left external carotid artery of deeply hypoechoic texture, showing no significant internal nor peripheral vascularity, measuring about 29 × 10 mm. CT scan with contrast of the neck showed left carotid space mass. MRI neck was done that showed a left para-pharyngeal carotid space solid lesion most likely either a carotid body tumor or a schwannoma for further workup. FNAC was not advised as it is contraindicated in cases of carotid body tumor. A 24-hour urinary metanephrines test was normal, which rules out paraganglioma. A decision to proceed for surgical excision was made.A final decision was made to proceed with a surgical excision of the tumor once the patient's informed consent was acquired. The patient was briefed about the surgical protocol and the risks such as bleeding, damage to nearby structures, or infection. The patient was booked for surgery at December 2021 for an elective excision of the mass.A left hockey stick incision was made 2 cm below the mandible, extended from the midline of the neck to 1 cm behind the sternocleidomastoid muscle. Incision of the subcutaneous tissue, superficial, deep and investing layer, platysma was done. Flaps were raised superiorly and inferiorly. Identification and incision of the carotid sheath layer was done. The carotid artery and internal jugular vein were mobilized and separated from the mass. The vagus nerve was identified, which was away from the mass. Ultimately, glossopharyngeal schwannoma capsule identified and excision of entire mass was done with the use of microscope. The histopathology result came out as glossopharyngeal schwannoma.The patient was routinely followed up after being discharged with standard pain management, and was seen 2 weeks, 3 months, 6 months, and 1 year post-op, and had no complications or complaints. The wound site also healed adequately.All activities and consultations mentioned have been conducted in Kuwait without any outsourcing of resources , Fig. 4.3The glossopharyngeal nerve emerges from the cranial part of the medulla and leaves as 3 or 4 roots in the groove between the olive and the inferior cerebellar peduncle directly superior to the vagus nerve. It unites into a single nerve bundle that enters the jugular foramen through its neural compartment . Most glGlossopharyngeal schwannomas are considered extremely rare, especially in the absence of underlying neurofibromatosis ,7. In liThe diagnosis of Glossopharyngeal Nerve Schwannoma involves physical examination, medical and familial screening for conditions such as NF2, and audiometric and hearing tests such as: otoscopy, Rinne and Weber tests, tympanometry, acoustic reflex, static acoustic measures, and auditory brainstem response and otoacoustic emissions. Relevant radiological investigations include: Computerized tomography (CT) scans of the head and neck with contrast, magnetic resonance imaging (MRI) with gadolinium, MR angiography, and also possibly positron emission tomography (PET) scans to rule out malignancy there is a metastases. Tissue biopsy is considered to be the gold standard in diagnosing glossopharyngeal schwannoma . The patSince specific clinical symptoms and radiological findings can be absent in most cases of glossopharyngeal schwannomas as presented here, the diagnosis might be challenging . The difSurgical excision is recommended for treating glossopharyngeal nerve schwannoma with preservation of CN9. In our case, surgical excision with a left hockey stick incision in the neck was done below the mandible. The glossopharyngeal nerve was identified intraoperatively. Most common complication of surgery is permanent nerve damage, so identification of the nerve must be done to avoid such complication.The prognosis of glossopharyngeal nerve schwannoma is generally positive, especially with preservation of the underlying nerve. In such cases, recovery from cranial nerve dysfunction after surgery is also fairly acceptable, although bilateral tumors and the positive history of neurofibromatosis can affect the outcome adversely. However, an early diagnosis and prompt management of the tumor will help improve the outcome. The chance of recurrence of glossopharyngeal nerve schwannoma after surgical excision is rare .4This report intends to provide another piece of literature that covers the incredibly rare condition of glossopharyngeal schwannomas, providing future practitioners insight towards the presentation of patients and differential diagnoses to note. This case report also provides insight towards the difficulty of diagnosing this condition, and discusses the ways it is diagnosed, with magnetic resonance imaging being the best tool pre-operatively and a tissue biopsy intra-operatively. As a conclusion, this case reports hopes to further the knowledge of this condition for the presentation, patient population, diagnostic, and surgical approach for this incredibly rare tumor by providing a peri-operative case report of a patient with the condition.Ethical approval was waived by the author's institution.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Dr. Essa Tawfeeq; data analysis and contributionDr Lulwah AlSaidan; data collection, data analysis, and write up.Dr Jafar Hayat; data collection and write up.Dr Bodour AlAbdulrahim; data collection and write up.Dr Mariam Sarkhouh; data collection and write up.Dr Mutlaq Al-Sihan; data analysis and contribution.Dr Lulwah AlSaidanN/AWritten 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.There is no conflict of interest to declare by any of the authors of this study.


A phytobezoar is a conglomerate of improperly digested fruit and vegetable debris, and its development is associated, amongst other factors, with previous gastric surgery. Most phytobezoars remain asymptomatic and are incidentally found during imaging or interventional procedures. However, in some patients, they can cause small bowel obstruction, which can subsequently lead to severe complications. Although the clinical findings are similar to other causes of intestinal obstruction, there are some particular diagnostic and treatment features more specific to phytobezoars. We present a case of an 85-year-old man with a history of previous antrectomy and Billroth II reconstruction who came to the emergency department with bilateral aspiration pneumonia and intestinal obstruction due to a bezoar. The CT scan showed bilateral inferior lobe pulmonary consolidation, as well as a marked dilation of the small bowel with gas-fluid levels and a transition to normal caliber in the terminal ileum, where an oval mottled-appearing mass suggesting a bezoar was present. An urgent laparotomy confirmed the diagnosis, and an enterotomy with removal of the bezoar was performed. Phytobezoars must be considered as a cause of intestinal obstruction, particularly when patients have a history of previous gastric surgery. Its radiological findings, particularly in CT scans, are specific and should be appreciated to establish the diagnosis promptly. The treatment of small bowel obstruction due to a phytobezoar requires surgery most of the time, and the surgeon must bear in mind the need to look for the existence of other bezoars in the gastrointestinal tract to prevent reoccurrence. Bezoars are unproperly digested conglomerates that form in the gastrointestinal tract, more frequently in the stomach. While many materials can cause bezoars, the most frequent are phytobezoars, which are made of undigested parts of fruits and vegetables ,2. Most An 85-year-old man, generally healthy and independent, presented to the emergency department with severe abdominal pain for the last 24 hours, vomiting, diffuse abdominal distension, and shortness of breath. He previously underwent antrectomy with Billroth II reconstruction due to a perforated gastric ulcer 40 years ago. He also had diabetes, treated with oral antidiabetic agents, and chronic obstructive pulmonary disease due to heavy smoking. On admission, he was tachycardic, with normal blood pressure, febrile up to 38.4 C degrees, had a peripheral oxygen saturation of 84% on a high flow mask, and consciousness impairment to Glasgow Coma Scale of 9. He was using accessory respiratory muscles and on auscultation had diminished breath sounds with bilateral rhonchi and crackles. The abdomen was distended and diffusely tender with absent bowel sounds. A nasogastric tube was placed with an immediate release of 2 litres of faecal content. Blood tests revealed raised inflammatory markers and the arterial blood gas showed a metabolic acidosis with type 1 respiratory failure and a lactate concentration of 4.7 mmol/L. The patient was intubated, and after prompt resuscitation was taken for a CT scan. Images showed a bilateral inferior lobe consolidation secondary to gastric content aspiration , followed by trichobezoars (made of hair), pharmacobezoars (made of medications), and lactobezoars (made of milk protein) . The occSeveral predisposing factors contribute to bezoar formation. It is reported that 42.8% of patients with bezoars had previous gastric surgery , and it Most bezoars remain clinically silent. Although bezoars can give origin to unspecific abdominal pain or postprandial fullness, the most important presentations are gastrointestinal obstruction or bleeding . ObstrucIntestinal obstruction by a bezoar has specific imaging findings. In plain abdominal films, besides the usual dilated small bowel loops with gas-fluid levels, if barium contrast is administered, it is possible to see an intraluminal filling defect, when barium fills the phytobezoar, which gives it a mottled appearance . The CT The treatment of small bowel obstruction starts off with adequate fluid replacement and intestinal decompression with a nasogastric tube. If the position of the bezoar allows it to be reached by an endoscopic method, it can be treated with mechanical disintegration and/or chemical dissolution. However, definitive treatment is usually surgical. Fragmentation and squeezing out the bezoar can be primarily attempted. In case it is not possible, an enterotomy to allow removal of the bezoar should take place, which can be open surgery or laparoscopic . SegmentIntestinal obstruction by a phytobezoar is a rare condition that can lead to devastating outcomes. This article showcases the importance of a detailed anamnesis when approaching a patient with intestinal obstruction. A patient with previous gastric surgery presenting with symptoms of intestinal obstruction should raise suspicion of a bezoar. Specific radiological findings, particularly the presence of a mottled-appearing mass at the obstruction point, can lead to early diagnosis and prompt management decisions. Finally, exploration during surgery to exclude the existence of other bezoars is essential in order to prevent further obstructions due to another bezoar left in situ.


Penile rings have been used to help sustain erection and enhance sexual pleasure for centuries. Constriction of the penis reduces the outflow of blood from the cavernosal tissue. However, if left for an extended time period, a condition called penile ring entrapment can occur. This may result in severe edema, gangrene, necrosis, and even penile amputation. Penile ring entrapment is a very rare condition; complete urinary obstruction with concomitant bladder rupture as a result renders this case even more extraordinary. We discuss our experience in the management of a 64-year-old man, who presented with altered mental status and inability to urinate, found to have penile ring entrapment and intraperitoneal bladder rupture. Removal of the constricting ring was performed in the ED, and bladder injury and penile necrosis were subsequently repaired with robot-assisted laparoscopic cystorrhaphy, penectomy, and perineal urethrostomy. Penile rings have been used for the purpose of enhancing sexual pleasure for centuries. They function by decreasing the outflow of blood from the erectile tissue, which results in sustained erection. Various materials such as wedding rings, rubber bands, “bull rings,” and plastic bottlenecks have been used , 2. PeniThe present case is particularly unusual given the initial presentation of concomitant bladder injury. Injury to the bladder is most commonly associated with iatrogenic injuries during pelvic or gynecologic procedures, as well as blunt and penetrating trauma . ManagemA 64-year-old male with a history of schizophrenia presented to the emergency department due to altered mental status and reported inability to urinate for 48 to 72 hours due to penile ring entrapment. Further questioning revealed the patient had attempted to masturbate using a 16-ounce soda bottle, which resulted in penile edema and subsequent entrapment. Initial physical examination revealed meatal stenosis, a bottleneck constricting the proximal penile shaft with findings concerning for penile dry gangrene . The botA basic metabolic panel revealed an elevated serum creatinine of 11 mg/dL. Bladder drainage was established with a Foley catheter after gentle dilation of associated meatal stenosis with an initial output of 300 mL of clear, light pink urine. The abdominal examination at the time of catheter placement was soft, nontender, and without signs of peritonitis. However, a bedside abdominal ultrasound performed by the emergency department physicians demonstrated free peritoneal fluid. A CT cystogram demonstrated contrast surrounding small bowel loops and a discontinuity of the bladder dome consistent with an intraperitoneal bladder rupture .Given the radiographic findings, surgical repair was recommended. Due to the isolated and straightforward nature of the defect, we proceeded with prompt surgical repair of the bladder injury with a minimally invasive approach using a DaVinci Robot™ . Insufflation of the peritoneal cavity to 15 mmHg was established with a Veress needle, and a supraumbilical robotic trocar was placed to serve as the camera port. Three additional 8 mm robotic trocars—one on the left and two on the right—were placed in line with the initial trocar, spaced evenly in a manner like robot-assisted radical prostatectomy. A final 12 mm laparoscopic trocar was placed in the left lower quadrant as an assistant port. After docking, copious intraperitoneal urine was evacuated using a laparoscopic suction, and a roughly 3 cm defect was readily identified at the bladder dome . The blaAfter a period of observation, the patient was brought back to the operating room 48 hours later for penile debridement. Figures Due to comorbid medical and psychiatric conditions, the patient remained inpatient until hospital day 14, 13 days after the index operation. On this day, new necrosis of the urethra was discovered, as pictured in Penile rings restrict the outflow of blood from the penile tissue resulting in a sustained erection for sexual pleasure. Improper use, however, can lead to tissue ischemia, edema, necrosis, tissue loss, and even death . Penile The uniqueness of this case involves not only the sheer extent of penile damage necessitating penile amputation but also the associated bladder rupture. Bladder injuries are more common than penile ring entrapments; however, they are more likely to be associated with trauma or iatrogenic injury. Clinical suspicion was raised in the present case due to a severely elevated serum creatinine level in the setting of prolonged urinary retention with only 300 mL of initial urine output upon Foley catheter placement.Management of bladder rupture has been thoroughly described by the American Urological Association . In our While rare, urologists should be aware of the possibility of bladder rupture in the setting of prolonged penile ring entrapment. When possible, we feel that a minimally invasive approach, whether laparoscopic or with robot assistance, is appropriate when the rupture is straightforward and lends itself well to such a technique. With respect to penile necrosis, preservation of tissue should be the goal to maintain urinary and sexual function; when necessary, however, a perineal urethrostomy may be performed if the necrosis is extensive.


Endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) plays an important role in obtaining pathology specimens from pancreatic lesions. FNB needles have been designed to acquire larger “core” specimens that preserve tissue architecture and permit histologic evaluation and immunohistologic stainingA 59-year-old woman presented with a 2-day history of abdominal pain. Her laboratory tests including liver function, pancreatic amylase, and tumor markers were all within normal limits. Computed tomography revealed a low-density round lesion measuring 4.5 × 5.1 cm in the head of the pancreas with invasion into the portal vein . PositrVideo 1 Endoscopic ultrasonography-guided fine-needle biopsy of primary malignant melanoma of the pancreas.To our knowledge, this is the first case of primary malignant melanoma of the pancreas diagnosed using the EUS-FNB technique. As our case has demonstrated, EUS-FNB was crucial for the tissue acquisition and pathological diagnosis.Endoscopy_UCTN_Code_CCL_1AZ_2AB


Cardiac cancers are exceedingly rare, mainly appearing as secondary cancers in patients with numerous systemic metastases, and are often detected by autopsies. Right ventricle (RV) metastasis from metastatic colorectal cancer (mCRC) is rarely reported in the literature. We report a 24-year-old man's case of mCRC, who developed positional variation in pulse rate while receiving the second cycle of chemotherapy. The echocardiography and chest computed tomography (CT) scan showed RV mass. The tumor was right-sided, and Kirsten rat sarcoma (KRAS) mutated based on that. He was treated with FOLFOX chemotherapy protocol plus bevacizumab and enoxaparin with an initial reduction in mass size. However, follow-up CT 9 months later demonstrated disease progression. For that, the chemotherapy was stopped, and the patient received palliative care. In conclusion, this case provides evidence that mCRC and RV location of metastasis can and do occur. In such a case, therapeutic intervention should be determined by weighing the benefits and risks. Cancers involving the heart are more commonly metastatic than primary, with a very poor prognosis . AlthougRight ventricle (RV) metastasis from metastatic colorectal cancer (mCRC) is rarely reported in the literature ,5. HereiPatient information: a 24-year-old single man, smoker, khat (Catha edulis) chewer, and soldier presented with abdominal pain, weight loss, and rectal bleeding in the last two months. The pain was generalized, severe and did not subside with medical treatment. He also mentioned a history of constipation and a change in bowel habits. The patient had no chronic medical conditions or family history of malignancy.Clinical findings: the patient's vital signs were as follows , 121 (in sitting) beats per minute). The chest and abdominal examinations were normal.Timeline: the timeline of all events is mentioned in Diagnostic assessment: laboratory tests were significant for Carcinoembryonic Antigen (CEA) of 17 ng/mL  with normal CA 19.9 of 7 ng/mL. Other laboratory tests were normal, including basic metabolic panel and renal and liver functions. The initial chest X-ray was unremarkable. Computed tomography (CT) scan of the abdomen and pelvis showed segmental significant circumferential mural thickening involving the sigmoid colon (about 6 x 1.4cm) and significant fat stranding. Another similar mass involves the distal rectum down to the anal verge (about 9 x 1.1 cm). A few prominent lymph nodes were seen within the mesorectum, para-aortic, and porta-hepatis, with the largest of the para-aortic group measuring approximately 17x22 mm (17x22 mm . Multipl17x22 mm . The cheTherapeutic interventions: the patient was diagnosed with mCRC (pT4N2M1) and treated with combination chemotherapy of 5-fluorouracil 400 mg/m2 bolus followed by 2400 mg/m2 as 46 hrs. infusion, leucovorin 20 mg/m2, oxaliplatin 85 mg/m2, every three weeks (FOLFOX regimen). Two weeks later, while receiving the second cycle of chemotherapy, we noticed positional variation in pulse rate (91 beats per minute in the supine position and 121 beats per minute in sitting). The electrocardiogram showed sinus rhythm. Echocardiography showed a filling defect within the RV measured about 19 x 10.5 mm, without pleural effusion or pneumothorax  and died due to heart failure two months later. Regardless, such cases remain extremely rare. Globally, colorectal cancer (CRC) represents the third most prevalent malignancy. Distant metastasis presents in almost 20% and 30% of cases at the time of diagnosis or during illness, respectively . CRC metet al. reported cardiac metastasis in 9.1% of all malignant tumors [More than 75% of primary cardiac tumors are benign, of which myxomas represent 50%, while sarcoma accounts for the remaining malignant cases. These tumors, however, are sporadic and diagnosed in only 0.001 - 0.28% of autopsy cases . On the t tumors . Other sMetastatic colorectal cancer (mCRC) has a median age of 70 years, ranging from 41 to 81 years, and predominantly affects males . Our caset al. reported that the interval appears to extend to 17 years after the initial diagnosis of CRC [et al. (4 months), Choi et al. (at the time), and our case (3 months) [The interval between the initial diagnosis of primary malignancy and the discovery of cardiac metastasis appears to be very wide, with controversy in the literature. While Sarfraz s of CRC . Others  months) ,9. Charaour case  months [ [et al.  months,  months) . Radiolo months) . In our et al. observed that obstructive and isolated lesions are particularly amenable to surgical therapy for symptom alleviation and life extension [Due to the rarity of CRC with cardiac metastases, surgery has not been studied extensively as a treatment approach. Although not usually advised for treating metastatic cardiac tumors, Koizumi xtension . The incet al. described a patient with mCRC to the liver 16 months after treatment, who presented with abdominal distension and exertional dyspnea coupled with a right atrial mass, advancement of liver metastases, new signs of ascites, and pleural effusions. His right atrial mass and ascites disappeared entirely after he had four monthly doses of irinotecan. Nonetheless, successive CT scans revealed a partial return of the right atrial tumor and increased CEA levels. Ten months following the resumption of irinotecan, the patient's symptoms were well-controlled [The treatment of mCRC with chemotherapy multiple therapy results in varying therapeutic responses; however, patients inevitably experience disease progression or recurrence. Choufani ntrolled .et al. featured an incidentally detected RV tumor with histopathology confirming the presence of wild-type KRAS. Surgeons considered the tumor unresectable. Following ten rounds of 5-fluorouracil, oxaliplatin, and panitumumab were administered to the patient, oxaliplatin was withheld due to neuropathy, and the patient was found to be in partial response after 12 courses . However, a follow-up CT after 15 cycles revealed increasing RV mass, and the patient chose palliative treatment but was still alive two years after the diagnosis [In comparison, a case described by Tsuji et al. described a patient with rectal carcinoma, persistently elevated CEA levels, and subsequent positron emission tomography (PET)/CT scan revealed a 6 x 3 cm tumor in the RV. With a palliative intent, the RV mass was resected and deemed histopathologically of rectal origin. A postoperative CT scan revealed the presence of a persistent intracardiac mass and pericardial effusion. After six cycles of FOLFIRINOX, the cardiac mass was found stable, and the pericardial effusion was reduced. The patient completed eleven FOLFOX cycles with no reported symptoms [et al. who received a FOLFIRINOX/ bevacizumab for mCRC to the right ventricle, and interestingly, the mass showed reduction in size following chemotherapy [De la Fouchardière symptoms . A similotherapy .Cardiac metastasis of colon cancer is a rare entity. Patients with CRC should be evaluated for possible cardiac metastasis upon developing new cardiac-related symptoms or identifying new cardiac lesions in imaging. Currently, there are no standardized approaches to treatment in patients with cardiac metastases from CRCs. More research is needed to determine the best treatment strategy for this group of patients.


Omental Infarction (OI) is uncommon and mimics common causes of acute abdomen. It is important to differentiate it from other abdominal conditions that require emergency management. It was first reported in literature in 1896 and about 400 cases have been reported till date.+0 Ibo house wife who presented with 10 years history of supra-pubic mass and five months history of excessive menstrual flow. After physical examination, a diagnosis of symptomatic uterine fibroid was made. She had myomectomy and the raw surface created after the excision of the myomas was covered with omentum. Wound infection developed on the 8th post-operative day leading to a wound breakdown and later partial extrusion of infarcted omental tissue through the dehisced wound. During re-exploration, the infarcted omental tissue was extracted and the residual abdominal abscess was drained. Surgical site wound infection occurred on the 3rd day after re-operation and a sub-acute intestinal obstruction developed on the 4th day thereafter which responded to conservative management.We reported on a 41 year-old Para 0Careful surgical technique is imperative when utilizing the omentum for reconstructive abdominal surgery. Torsion of the omentum and creation of excess tension while using the omentum for reconstructive procedures should be avoided and increase awareness of this uncommon disease condition by the surgeon is also important. This case is to report a rare finding of omental infarction following myomectomy. Omental Infarction (OI) is uncommon and mimics common causes of acute abdomen such as acute appendicitis, cholecystitis, diverticulitis, perforated duodenal ulcer, mesenteric thrombosis and twisted ovarian cyst. –5OI was first reported in literature in 1896 by Eithel , 4, 6–8 The incidence of OI is increasing due to the advent of advanced radiological investigations such as ultra-sonographic scan, computerized tomographic (CT) scan, magnetic resonance imaging (MRI) and laparoscopy which are useful tools for diagnosis and in some cases for treatment . AwareneThe aim of this case report was to highlight an uncommon case of secondary omental infarction following the use of omentum to cover the deperitonised portion of the uterus after myomectomy and to caution on its appropriate use by avoiding overstretching, excessive torsion and kinking.+0 Ibo house wife who presented with 10 years history of a supra-pubic mass which progressively increased in size and five months history of excessive menstrual flow. She could not seek for medical help early enough on account of financial constraints, until her church came to her aid. She was married for 10 years, living intimately with her husband and having adequate sexual intercourse without a conception prior to presentation.We reported on a 41 year-old Para 0She was a public servant with no history of diabetes or hypertension. Past medical and family histories were not contributory. She neither smoked nor consumed alcohol. She volunteered a history of adverse reaction to chloroquine, amoxycillin and clavulanic acid medications. There was no antecedent history of blood transfusion.At presentation she looked pale and was afebrile to touch, had a temperature of 36.5 °C, a respiratory rate of 24 cycles per minute, a pulse rate of 84 beats per minute, blood pressure of 130/90 mmHg and a body mass index (BMI) of 20.3. Her packed cell volume was 24%, urinalysis showed significant pyouria. Electrolytes, urea & creatinin and clotting profile were normal. Abdominal sonogram revealed multiple huge uterine fibroids.The essential findings were in the abdomen. The uterine size was equivalent to 28/52 gestational age and there were no other organomegaly. Vaginal examination did not provide any additional information. A diagnosis of a symptomatic uterine fibroid was made and she was worked up for elective myomectomy after counselling and treated for urinary tract infection with oral ciprofloxacin 500 mg twice daily for five days. She also received three units of blood before surgery.Prophylactic antibiotics 200 mg of ciprofloxacin and 500 mg metronidazole were also administered intra-venously. Under subarachnoid block anaesthesia she had exploratory laparotomy done through a long midline incision extended above the umbilicus for adequate access. The findings at surgery were a bulky uterus with multiple, widely distributed, varied sized fibroid masses and adenomatous tissues. The uterus was infiltrated with desmopressin 4mcg diluted in 200mls of normal saline and a tourniquet was applied at its base to minimize bleeding. A deperitonised area on the posterior wall of the uterus after myomectomy was covered with omentum sutured around the defect to prevent anticipated bowel adhesions. She received two units of blood intra-operatively.She developed a fever on the day of surgery through the 5th day post surgery which we attributed to febrile blood transfusion reactions and to malaria fever which is prevalent in our sub-region. Malaria parasites were seen in her blood film. She received appropriate doses of anti-malarial drug, intramuscular injection of artemether 80 mg twice daily for three days anti-histamines, intra-venous promethazine 25 mg stat dose and hydrocortisone 200 mg stat dose. She was discharged home on the 6th day post-operation.On the 8th post-operative day she presented from home with profuse, purulent and foul smelling discharges from a wound sinus. About 200mls of pus was drained and a wound swab taken for microscopy, culture, and sensitivity. All the stitches were removed and a wick-drain dressing commenced. The wound culture did not yield any growth after three days. On the 36th day post-operation, a blister was noticed in the area of the wound sinus, which ruptured spontaneously and resulted in a wound breakdown three days later.Seven days after the wound break down that is 46th day post-operation, a gangrenous tissue was observed extruding from the dehisced portion of the wound Fig. . On geneThe patient was re-admitted, optimised for emergent surgery, rehydrated with three litres of 5% dextrose saline given over four hours, given parenteral anti-biotic therapy of ceftriaxone two grams and metronidazole 500 mg and a unit of blood transfusion. The findings at re-exploration were an infarcted omental tissue partially extruding through the dehisced wound and extending into a pocket of pus on the floor of the pelvis. Other pelvic organs including the uterus were normal. The infarcted tissue was easily and completely extracted leaving a residual cavity full of pus and the infarcted tissue was sent for histology. A copious saline lavage of the cavity was done and a drain was left in the residual cavity. The abdominal wound was closed in a single layer. Parenteral broad spectrum anti-biotics which were used for prophylaxis were continued post-operatively. Surgical site wound infection occurred on the third day of post re-operation.A day later, patient developed signs and symptoms of partial intestinal obstruction which was confirmed by abdominal radiography. The obstruction resolved after four days on conservative management which involved nil per mouth, intravenous infusion of 500mls 5% dextrose saline administered four-hourly, placement of nasogastric tube and the continuation of the parenteral antibiotics. The patient was eventually discharged home on the 11th day of re-admission. A four-month follow up was uneventful.This case is to report a rare finding of omental infarction following a myomectomy.Omental infarction is not a common disease condition and since it was first described in 1896, only about 400 cases have been described till date , 10. OI OI can either be primary (idiopathic) or secondary. The unnecessary length of omentum, its tenuous vasculature, increased abdominal pressure and increased peristalsis from over eating are some of the patho-physiological mechanisms involved in idiopathic omental infarction (IOI) .Precipitating factors in IOI include obesity, 40–50 age group, male gender, exertion, local trauma, occupational vibration, excessive straining and coughing and sudden change in posture , 2. OmenSecondary causes of OI include strangulated inguinal hernia, intra-abdominal tumours, pelvic inflammatory disease, post-operative venous thrombosis, arterial ligation and kinking from adhesions from previous abdominal surgery , 6. SecoOn account of the proclivity of the omentum for adhesion formation, neovascularisation, defence against infection and its abundant availability in length, it is used in the reconstruction of defects in abdominal and pelvic surgeries . These pThe right side of the omentum is more involved than the left on account of its longer length and more mobility and for this reason the resultant abdominal pain is often right sided in 90% of cases , 5, 11.In the presence of predisposing and initiating factors, torsion of the omentum occurs along its long axis and on its narrow pedicle causing the kinking of the veins and arteries leading to venous stasis, thrombosis, haemorrhagic infarction and finally fat cells necrosis , 10. OI Abdominal ultrasonography (USS) and computed tomography (CT) scan are useful tools in the pre-operative diagnosis of OI , 4, 12 aHistological features of OI consists of focal necrosis, and fibroblastic reactions . These wThere was leucocytosis and anaemia in this case similar to other studies  probablyThis case had exploratory laparotomy, removal of the infarcted tissue and drainage of the abscess collection in the peritoneal cavity unlike some cases of idiopathic omental infarction where treatment is often conservative. The option of conservative management requires confirmation and follow up with ultra-sonographic or CT scan. Failure of expectant management may lead to definite treatment by open omentectomy or by laparoscopic excision of the infarcted omentum , 4, 5. IThe omentum is useful in reconstruction in abdominal and pelvic surgery . In our Omental infarction is a rare disease and may mimic common causes of acute abdomen such as acute appendicitis, cholecystitis, diverticulitis, perforated duodenal ulcer, mesenteric thrombosis and twisted ovarian cyst. Secondary omental infarction may result from the use of the omentum for reconstruction in pelvic surgery such as after myomectomy. When the omentum is used for reconstructive surgery, utmost care must be taken in the handling of the omentum, ensuring that tension, twisting and kinking are avoided. It is worth noting that OI has a favourable prognosis when properly managed. Surgeons' awareness of OI, the use CT scan and laparoscopic approach to management is imperative . OI has


Gastrinomas can often be cured with surgical removal if detected early enough. We present a case report where a patient was diagnosed with gastrinoma with relatively low serum gastrin levels after subsequent duodenojejunostomy, gastrojejunostomy, total gastrectomy, and cholecystectomy. With this case report, we hope to promote a higher level of awareness of pancreatic neuroendocrine (NE) tumors and educate clinicians on the full effects of proton pump inhibitor (PPI) use on patient workup, diagnostics, and care. Gastrinomas are a relatively rare form of neuroendocrine (NE) tumor, with an annual incidence rate of 0.5-2 per million -3. TheseGastrinomas most commonly occur in the gastrinoma triangle , formed by the pancreatic head/neck, the confluence of the cystic duct and common hepatic duct, and the second and third parts of the duodenum ,9. Some Gastric acid is typically secreted by the G cells located within the stomach and pancreas . The excThe best initial test for diagnosing a gastrinoma is an esophagogastroduodenoscopy (EGD), revealing ulcerations and thickened gastric folds, a decrease in gastric pH, and an increase in basal acid output of greater than 15 mEq per hour ,12,13. TThere is a clear need to create more accurate and precise diagnostic methods for the diagnosis of gastrinomas. Immunoassay kits historically vary significantly in their accuracy; a study evaluating 12 different kits showed that 33% of kits returned falsely low results in 20%-80% of the patients ,15. Anot68GA)-labeled somatostatin radiotracers used with positron emission tomography/computed tomography . Radiolabeled indium-111 octreotide scans can also be done, wherein radiolabeled octreotide is taken up by somatostatin receptor-expressing cells. These receptors are maximally expressed in most well-differentiated NE tumors [Computed tomography (CT) scan or positron emission tomography (PET) scan can also be of use in the diagnostic process. A mass in stereotypical locations for NE neoplasms can be seen, in combination with elevated gastrin levels . DiagnosE tumors .Due to the rare number of cases each year, gastrinomas are often underdiagnosed, and those that are caught often progress to the point of distant metastasis (most commonly the liver) . Over 60Immunohistochemistry can be done to confirm the diagnosis of NE tumor after the subsequent biopsy or removal of the tumor. Common positive stains for gastrinoma include synaptophysin, chromogranin, gastrin, pancreatic and duodenal homeobox 1 (PDX1), and Insulin-associated protein 1 (INSM1) . GastrinAfter nine years of multiple ER visits, many surgical consults, gastroenterologist visits, surgical and diagnostic procedures including numerous imaging modalities, and medication administration and changes, a 26-year-old obese Hispanic male was ultimately diagnosed with and received treatment for a gastrinoma.He originally presented to the ER in 2013 for abdominal pain, nausea, vomiting, and diarrhea. His past medical history at the time of initial symptom onset included diagnoses of type II diabetes mellitus, obesity, hyperlipidemia, and hypertension. He had no significant past surgical history or social history at the time of original symptom onset. His family history was significant for unknown cancer in his mother and brother. This was his first time experiencing these symptoms, and he was subsequently diagnosed with unspecified noninfectious gastroenteritis and discharged home. A timeline of events can be seen in the Appendices.Over the course of roughly five years, beginning in 2018, the patient would return to the ED multiple times with similar symptoms, being discharged with a diagnosis of fatty liver disease and gastroenteritis after an abdominopelvic CT series . There is documentation that the patient was taking PPIs during this time period. Images taken in November 2020 after these findings showed marginal ulcerations, findings consistent with status post truncal vagotomy and antrectomy. The patient subsequently underwent a near-total gastrectomy for symptomatic relief. The pathology reports of specimens collected during the procedure showed the presence of an ulcer bed with hemorrhage, transmural inflammation, and suggestions of a fissuring ulcer with scattered multinucleated giant cells and fibrous thrombi.The persistence of these symptoms despite intensive medical and surgical interventions raised concern for a gastrinoma, even in the context of only mild hypergastrinemia. In January 2021, the patient’s gastrin levels were measured again, and the results showed a gastrin level of 279 pg/mL. There is documentation that the patient was asked to stop PPI use for two weeks prior to measuring gastrin levels. A CT was performed shortly after gastrin levels were collected, and radiology reported no significant findings. The results of an octreotide scan performed in January 2022 showed attenuation and uptake in the localized area of tumor location without signs of metastasis. In February 2022, another CT was collected at an outside facility, which reported a mass near the caudate lobe of the liver; this can be seen in Figure A month after the PET scan, the patient underwent surgical excision of the mass. The enucleation of the tumor was successful, and gross images were taken both during surgery, and gross specimens following excision can be seen in Figures A three-month gastrin level was collected, measuring serum gastrin at 10 pg/mL. PET/CT imaging revealed a mildly fluorodeoxyglucose (FDG)-avid lesion in the region of the porta hepatis, without any discrete abnormality identified in the area.Depending on their hormonal output, functional NE tumors present primarily in different ways. In gastrinoma, the presentation often depends on gastrin overproduction. Studies reveal that the usual presenting symptoms of gastrinomas include abdominal pain, diarrhea, or both in 75%, 73%, and 55% of the patients, respectively, with heartburn being reported in 44% of the patients . DiagnosTraditionally, the diagnosis of gastrinoma is confirmed with gastrin levels 10 times the upper limit of normal (or 1000 pg/mL) in the presence of gastric pH of less than 2 . GastrinThe delay of the patient’s initial symptoms to the time of diagnosis is fairly typical of a gastrinoma masked by PPI usage. While PPIs are an established symptomatic treatment for the condition ,20, the The best initial test for diagnosing a gastrinoma is an EGD, revealing ulcerations and thickened gastric folds with a decrease in gastric pH and an increase in basal acid output of greater than 15 mEq per hour ,12,13. TWhile the diagnosis of gastrinoma is often supported with CT scan or PET scan as mentioned above, these modalities are not perfect diagnostic solutions. The sensitivity of CT scan imaging for the diagnosis of gastrinomas varies from about 29% to 51% with even lower sensitivities found for extra-pancreatic primary tumors; the overall performance of CT scans is very poor for tumors that are less than 3 cm in size. Slightly higher sensitivities are reported for the disease with concurrent liver metastases -26. PartSomatostatin receptor scintigraphy (SRS) has a high sensitivity for assessing the extent of gastrinoma stage. SRS has become the imaging study of choice for identifying primary tumors and metastatic lesions; however, sensitivity to detect gastrinomas is dependent on the size ranging from 30% for gastrinomas smaller than 1.1 cm to 96% for gastrinomas larger than 2 cm ,29-31. WSerum CgA levels are a common tumor marker that is used to help diagnose and follow disease progression and treatment response. CgA levels were measured in this patient in February of 2022 with resulting levels at 359 ng/mL (N: <311 ng/mL). Subsequently, levels were measured numerous other times resulting in values ranging from 111 to 197 ng/mL. The sensitivity for CgA levels is roughly 80%, and the specificity of the test is roughly 95% . FollowiA majority of gastrinomas occur sporadically, with only ~25% of the cases due to MEN1 mutations, which are also associated with pituitary, parathyroid, and pancreatic tumors. Due to negative family history, normal calcium levels, a solitary gastrinoma, and the lack of associated clinical features, this case is believed to be sporadic in nature. A return of all tumor markers to normal levels post-excision supports this theory.Similar to our case, the previous cases of gastrinoma diagnosis have been confounded with PPI usage creating reduced gastrin levels, which have been reported. In a case report by Wong et al. , a 58-yeThis case report illustrates the need for a more prompt diagnosis of gastrinomas and other NE tumors. Even if the patient does not fit the stereotypical clinical picture of an NE tumor, such as our patient’s gastrinoma, it does not indicate criteria to exclude the diagnosis from differentials when addressing recurrent symptoms. This case serves as a good reminder to all diagnostic clinicians, regarding many diseases and diagnoses. More careful evaluation of CT scans and imaging needs to be done, with the long-term clinical picture of the patient in mind. Had our patient’s neoplasm been visualized by radiologists and practitioners sooner, the outcome may have been drastically different. Additionally, had most physicians not dismissed the idea of this patient having a gastrinoma, perhaps a more prompt diagnosis could have been made, saving this patient from an immense amount of pain, suffering, and potentially unnecessary medical intervention. With this case report, we hope to not only promote a higher level of awareness of pancreatic NE tumors and the importance of quality detailed radiologic reports correlated to the clinical signs and symptoms but also remind clinicians of both the benefits and potential pitfalls of PPI use in patients with unremitting nonspecific GI symptoms of abdominal pain, nausea, vomiting, and diarrhea.