Replaced right hepatic artery (rRHA) is a common vascular variation, and combined resection of this vessel is sometimes needed for the curative resection of pancreatic head malignancy. Safe surgical management has not been established, and there is a small number of reported cases. Here, we reported five cases, wherein preoperative embolization of rRHA was performed for combined resection.All patients had pancreatic head malignancies that were in contact with rRHA. We performed a preoperative embolization of the rRHA before the scheduled pancreaticoduodenectomy for the combined resection. Arterial embolization was safely accomplished, and the communicating arcade from the left hepatic artery via the hilar plate was clearly revealed in all cases. Four patients underwent the operative procedure, except for one patient who had liver metastasis at laparotomy. No patient suffered from a severe abnormal liver function during the management; however, one patient had multiple liver infarctions during the postoperative course.Preoperative embolization for the combined resection of rRHA in pancreaticoduodenectomy can be a management option for the precise evaluation of hemodynamics after sacrificing rRHA. In our cases, arterial flow to the right liver lobe was supplied by the left hepatic artery via the bypass route, including the communicating arcade of the hilar plate. Hepato–biliary–pancreatic surgeons frequently encounter the anatomical variation of the hepatic artery, with replaced right hepatic artery (rRHA) being one of the most common variations –4. When As an alternative approach, we have adapted preoperative embolization management for combined resection of rRHA in PD. This approach may enable preoperative evaluation, development of collateral vessels, and simulation of the hemodynamics of the liver. Recently, a French study treated 18 cases with this approach and reported its safety and feasibility . In the We have adapted the planned preoperative embolization of rRHA in five patients who underwent PD with combined resection of rRHA in our institute between 2013 and 2019. The presence of tumor abutment or involvement of the rRHA on preoperative computed tomography (CT) was the indication for combined resection of the rRHA. The characteristics of the patients are summarized in Table Four patients were diagnosed with pancreatic ductal adenocarcinoma (PDAC), and the fifth was diagnosed with distal bile duct cancer. The PDAC lesion was resectable in two patients, borderline resectable in one patient, and one patient had locally advanced PDAC, according to the NCCN guidelines. The patient with borderline resectable PDAC (Case 2) presented with a tumor adjacent to the common hepatic artery and received neoadjuvant chemotherapy with gemcitabine and S-1. The patient with the locally advanced-type lesion (Case 3) presented with a tumor adjacent to the aorta and received multidisciplinary treatments, including chemoradiotherapy with S-1, followed by systemic chemotherapy with gemcitabine and nab-paclitaxel. The main tumor shrank partially after the therapies without developing distant metastasis; therefore, we decided to perform conversion surgery.In all five cases, preoperative arterial embolization was safely accomplished by interventional radiologists using the coil or vascular plug, and the collateral artery was evaluated after embolization (4–15 days before surgery). Postponing the surgery was an option if complications such as severe liver dysfunction or infarction occurred after embolization. The arterial flow was reassessed using CT before surgery. We routinely performed follow-up CT scans on post-operative days 7–10 to identify occult liver ischemia, intra-abdominal abscess, and obstruction of vessels. We performed a subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) in the four cases, but did not adapt the procedure for a case because of liver metastasis on laparotomy (Case2). In all four cases of SSPPD, we resected the rRHA with the main tumors without any reconstruction.We present a case representative of our management therapy, ensures effective management of this disease , 15. TheIschemic changes in the liver or bile duct after the resection of the hepatic arteries can cause postoperative complications, such as hepatic infarction, hepatic abscess, or anastomotic failure of cholangiojejunostomy , 19–21. After injury or occlusion of the hepatic artery, some intra- or extra-collateral arteries protect the liver from ischemia –29. PrevIn the present study, arterial embolization conducted by interventional radiologists was successful in all patients. However, major or minor complications associated with arterial embolization cannot be ignored , and proWe encountered a case of multiple liver infarctions without liver dysfunction (Case 3). The patient had severe changes in vital signs due to hemorrhagic shock and other complications during the postoperative course. Total blood flow to the liver may decrease after resecting rRHA, and systemic blood flow reduction due to shock may cause liver ischemia. Marichez et al.  reportedThe limitation of this report is that it was a small case series without a comparison between the cases. Although more cases are needed to verify the effectiveness or safety of our strategy, it could be a choice of surgical management for the malignancy of the pancreatic head with rRHA. Angiography findings after rRHA embolization could be useful for understanding hemodynamics after sacrificing this artery.From our five cases, preoperative embolization strategy for the combined resection of rRHA in pancreaticoduodenectomy could be a feasible choice for surgical management. The communicating arcade via the hilar plate from the left hepatic artery was one of the major routes bypassing the right hepatic lobe in these settings.


We present a case of chondroblastoma-like chondroma (CLC) of soft tissue that manifested as a palmar mass on the left hand of an 84-year-old man. Physical examination, imaging investigation, and needle biopsy initially suggested a giant cell tumor of the tendon sheath, until a correct diagnosis was made based on excised specimen histology. The patient underwent a marginal excision for soft-tissue mass removal. Follow-up examination showed excellent relief of symptoms, and full hand mobility was regained. The diagnosis of CLC is challenging because the radiographic and pathological features vary. Therefore, we highly emphasize the importance of utilizing excisional tissue for histopathological assessment in atypical chondroma presentations. Soft-tissue or extraskeletal chondromas are rare, slow-growing, benign neoplasms, which are predominantly formed by the hyaline cartilage . These tAlthough most soft-tissue chondromas are completely composed of the lobular, mature hyaline cartilage, different histological variants have been recorded , includiAn 84-year-old man with diabetes mellitus, hypothyroidism, ischemic heart disease, and benign prostatic hyperplasia on medical treatment was referred to our clinic with the complaint of a painless mass in the palmar aspect of his left hand. Hand function was affected, and the patient had difficulty in gripping and holding objects for approximately one year. No constitutional symptoms were present, and there was no history of malignancy.On physical examination, a mass was found in the volar aspect of his left hand (zone 2), over the second and third metacarpals and the metacarpophalangeal joint (MCPJ), with a normal overlying skin. The mass was well defined, firm, fixed, nontender on palpation, and measured 3 × 2.5 cm in diameter. The digital range of motion and neurovascular examination findings were normal.Plain radiographs in anteroposterior and oblique views demonstrated a heterogeneous soft-tissue swelling with calcification in the anterior aspect of the second MCPJ Figures , 2. MoreA core needle biopsy showed the proliferation of predominantly round cells, with a low to moderately abundant eosinophilic cytoplasm. The nuclei were ovoid and showed nuclear grooves, and the matrix was predominantly chondroid with foci of coarse granular calcification. These features were suggestive of a chondroid process and justified a surgical resection of the entire lesion for proper classification and characterization.The patient was admitted and underwent a marginal excision of the soft-tissue mass, based on the results of the core needle biopsy, through a palmar incision over the apex of the mass and an extended Z-shaped incision at the distal palmar crease. Resection of the tumor revealed a yellow-tan, well-circumscribed solid lesion measuring 4 × 4 × 2 cm, which was carefully dissected and completely removed as a single mass. The digital nerve of the index finger and vessels was identified and dissected away from the mass. It was attached to the paratenon of the second flexor tendon, which was saved and protected. A careful homeostasis was achieved. The closure was performed in layers, and a soft dry dressing was applied. The surgery was uneventful, with no surgical or postoperative complications. The final report of the histological sections showed a well-circumscribed and markedly lobulated cellular neoplasm, composed of chondroblast-like cells with round to oval nuclei and a moderately abundant eosinophilic cytoplasm. The nuclei had notches and small but prominent nucleoli. A few osteoclast-like giant cells, as well as prominent chicken-wire calcifications, were noted. There was no frank cytological atypia, necrosis, or increased mitotic activity Figures , 7, 8. AThe patient was routinely followed up in the clinic after surgery and started hand-strengthening and range-of-motion exercises with a physiotherapist. Follow-up examination of the patient showed excellent relief of symptoms. He regained full mobility of the hand; the wound was healed, and the stitches were removed. Upon follow-up, there was no clinical or radiographic evidence of tumor recurrence, and the patient remained free of symptoms.Chondromas of soft tissue are rare, non-malignant tumors that constitute 1.5% of total soft tumors . Most ofCLCs have been macroscopically described as ovoid nodules or multinodular fragments with a tan-pink to tan-yellow color and a firm to rubbery consistency, which is similar to our findings ,6. HistoIt is unusual for a soft-tissue chondroma in the hand to show calcifications on plain radiographs. Moreover, typical MRI findings for chondromas demonstrate minimal perilesional inflammation and a high T2 signal. As these radiological features were not consistent with our case findings, we proceeded with a core needle biopsy, followed by a marginal excision, to determine the correct pathology.Based on the literature and our own experience, the recommended management for rare CLCs of the hand is a conservative excision since the clinical behavior of CLC is benign and nonaggressive. However, local hand recurrence has been reported in a few cases during an observation period of 1-10 years following excision [This case illustrates how this condition may represent a diagnostic challenge due to variable radiographic and pathological features. We attempted to highlight the clinical examination, possible diagnostic imaging, and surgical findings, in addition to the more commonly highlighted histopathology. MRI may help differentiate CLC from more common hand tumors, but an excisional tissue diagnosis is needed for clarification. Diagnosis based on core biopsy alone should be avoided because it will likely fail to show the varied microarchitecture that is indicative of CLC.CLC is a rare variant of soft-tissue chondroma, which mostly occurs in the hands. Owing to its expression as secondary degenerative features, the diagnosis of this condition is challenging. Therefore, we highly emphasize the importance of utilizing excisional tissue for histopathological assessment in atypical chondroma presentations.


Acinetobacter baumanii-related hospital-acquired pneumonia two weeks after initiation of chemotherapy. We performed a literature search and found five cases of pituitary apoplexy secondary to haematological malignancy-related thrombocytopenia. The usual age of presentation was in the 6th to 7th decade, and there was slight male preponderance. The underlying pituitary adenoma was either nonfunctioning or a prolactinoma, and in majority, the apoplexy event occurred after the diagnosis of haematological malignancy. The platelet counts at the time of PA were less than 30 × 109/L in all, and the malignancy subtypes were acute or chronic myeloid leukemia and chronic lymphoid leukemia. The current case highlights the importance of careful evaluation for the cause of thrombocytopenia in a case of PA.Thrombocytopenia as a precipitating factor for pituitary apoplexy (PA) is very rare event. There are only five reported cases of PA secondary to thrombocytopenia caused by underlying haematological malignancy. Herein, we report a case of 60-year-old male presenting with acute-onset headache, bilateral vision loss, and ptosis. Computed tomography and magnetic resonance imaging revealed findings indicative of pituitary adenoma with apoplexy. He was noted to have thrombocytopenia, and bone marrow evaluation revealed precursor B-lineage CALLA-positive acute lymphoblastic leukemia. Accordingly, he was started on dexamethasone and vincristine but succumbed to  Pituitary apoplexy (PA) is a clinical syndrome characterized by acute-onset headache caused by sudden hemorrhage and/or infarction. Precipitating factors are identified in only 20 to 40% of the cases . Though A 60-year-old male presented to the emergency department with chief complaints of sudden-onset headache, vision loss in both eyes, and drooping of eyelids for the last two days. On initial evaluation, he was haemodynamically stable, conscious, and fully oriented. Positive findings on examination included bilateral absent light perception, complete external ophthalmoplegia, bilateral ptosis, optic atrophy, and gynaecomastia Figures . A nonco9/L; DLC: Ne52, Ly42, Mo06%; and Plt: 23 × 109/L) for which bone marrow evaluation was performed. This revealed 70% blast cells that were cytochemically myeloperoxidase negative and on flow cytometry expressed CD19, CD10, CD81, HLA-DR, CD58, and CD38 along with cytoplasmic CD79a, CD22, and nuclear TdT. The blasts were negative for T/NK cell and myeloid lineage markers, as well as for CD86, CD34, and CD123. CD20 was dim to negative. Reverse-transcriptase PCR was negative for t , t , and t . The final hematological diagnosis was precursor B-lineage CALLA-positive acute lymphoblastic leukaemia  along with steroids. The resolution of sellar mass was seen in two cases, one managed with TSS while other conservatively , hemiplegia, hypotension, and altered sensorium. True apoplexy  is an uncommon event occurring in 2 to 10% of pituitary adenoma . The two9/L at presentation. Our case had a nonfunctioning pituitary adenoma and presented in the 6th decade with a platelet count of 23 × 109/L. However, it was unusual in that the apoplexy event was the presenting manifestation of an underlying haematological malignancy and highlights the importance of keeping this rare possibility in a case of PA with thrombocytopenia. Furthermore, the possibility of leukemic malignant cell infiltration into the pituitary adenoma cannot be ruled out in the current case, a rare but known event . T–9. T5–9]wn event . However9/L [Another important issue pertains to the management of PA in the setting of thrombocytopenia. Both medical and surgical treatments are available for management of PA. The aim of surgery is to decrease the intrasellar pressure in order to decompress the optic chiasma and the nerves in cavernous sinus. Except in a scenario of worsening neurological status in whom surgery is indicated, at present, there is no clear recommendation as to the mode of therapy with the best outcome . Further9/L . In rega9/L –13. HencIn a case of pituitary apoplexy associated with thrombocytopenia, a systematic evaluation for the cause of the latter is required. The selection of the management modality in such cases should balance the risk of perioperative hemorrhagic complications with that of uncertain long-term benefits of surgery, and such cases are likely to be better managed by a multidisciplinary team.


Small intestine duplication cysts (SIDCs) are rare congenital anatomical abnormalities of the digestive tract and a rare cause of hematochezia.We describe an adult female presented with recurrent hematochezia. The routine gastric endoscope and colonic endoscope showed no positive findings. Abdominal CT scan indicated intussusception due to the "doughnut" sign, but the patient had no typical symptoms. Two subsequent capsule endoscopes revealed a protruding lesion with bleeding in the distal ileum. Surgical resection was performed and revealed a case of SIDC measuring 6 * 2 cm located inside the ileum cavity. The patient remained symptom-free throughout a 7-year follow-up period.SIDCs located inside the enteric cavity can easily be misdiagnosed as intussusception by routine radiologic examinations. Enteric duplication cysts (EDCs) are rare congenital anatomical abnormalities of the digestive tract with an incidence of one in 4500 . EDCs arHematochezia is a difficult matter in clinics and may even be life-threatening. Causes for hematochezia include peptic ulcer, Meckel’s diverticulum, intussusception, and EDC. Sometimes, differential diagnosis is difficult. Small intestine duplication cysts (SIDCs) were mostly located outside the digestive tract . NotablyA 31-year-old woman was admitted with intermittent hematochezia for a month and a recurrence three days ago. She has no special past medical history. Physical examination revealed no abnormalities with stable vital signs. Hemoglobin levels varied between 50 and 90 g/L , and fecal occult blood testing was positive. Routine coagulation indicators and tumor markers, including carcinoembryonic antigen (CEA) and carbohydrate antigen 19–9 (CA19-9), were within normal ranges. The rapid and massive hematochezia resulted in shock after admission. After initial resuscitation, the patient underwent gastric endoscope and colonoscopy examinations without positive findings. Abdominal computed tomography (CT) identified an indistinct ileocecal structure with a "doughnut" sign, suggesting intussusception of the small intestine  a close attachment to the digestive tract; (b) a smooth muscle layer in its wall; and (c) a mucosal epithelial lining that resembles any part of the digestive tract . FurtherEDC patterns can be categorized into three types based on anatomy: saccular  cysts, tubular cysts, and small intramural cysts . Saccula. [. [The pathogenesis of EDC has not been fully understood, and many hypotheses have been raised, such as partial or abortive twinning, split notochord theory, embryonic diverticula, diverticular and canalization defects, intrauterine vascular accident, and environmental theory. None of these theories can adequately explain all known EDCs . Partial.  hypothes.  suggests. [.  proposedThe manifestations of EDCs often vary based on the different locations in the digestive tract. Most of them are asymptomatic and some have symptoms, including feeding intolerance, abdominal pain, nausea, acute intestine obstruction, perforation, hematochezia, and palpable abdominal mass according to physical examination . Among tIt is generally difficult to establish a confirmed diagnosis of EDC. X-ray results may be normal as the intestines are not being manifested very well and contrast examination is helpful to show the communication between the EDC and the native digestive tract . A diagnAs for the application of capsule endoscopy in similar cases, we have several issues to emphasize. First, the characteristic CT findings of intussusception include: (1) a thickened segment of the bowel due to the invagination of the intussusceptum into the intussuscipiens; (2) an eccentrically located lucency representing the mesentery of the intussusceptum and intraluminal air sandwiched between the two layers of the telescoped bowel; and (3) a mass, which usually represents the leading point . Given tOnce the diagnosis of EDC has been made, treatment is necessary to alleviate symptoms and prevent potentially serious complications, including intestine obstruction, intussusception, or hematochezia. The treatment approach for most EDCs is surgical resection. Resection can be performed through traditional open access approaches, as well as thoracoscopic and laparoscopic approaches. Important principles also include the identification and preservation of the blood supply to the native bowel .Duplication cysts of the jejunum and ileum are the most common EDC types. Generally, cystic lesions are easily resected. Tubular lesions are often complex with the involvement of surrounding structures. Consequently, a portion of the native bowel must be resected along with duplication and primary anastomosis performed . EDCs ma. reported a case report of peritoneal metastatic adenocarcinoma possibly due to a gastric duplication cyst with unsuccessful resection and the ruptured cyst contaminating the peritoneal cavity. It emphasized the importance of accurate preoperative diagnosis and optimal surgical management for gastric duplication cyst due to the potential existence of malignant transformation in adult patients with gastric duplication cysts [. reported the first case of papillary adenocarcinoma derived from colon duplication [Even though malignant transformation is extremely rare in EDCs, it needs to be carefully evaluated and addressed. Malignant transformation in SIDCs is described most frequently. If transformation change is found in SIDC, the high rate of lymphatic node metastases should be considered. Curative resections have been difficult to perform and the prognosis is generally poor . There aon cysts . Lee et lication .As such, SIDC may be the most likely cause of recurrent hematochezia in our case and should be resected to prevent the recurrence of hemorrhage after surgical consultation. Exploratory resection was successfully conducted and revealed a lesion located inside the enteric cavity. Pathological examination confirmed the definitive diagnosis of SIDC.We reported an extremely rare case of SIDC located inside the distal ileum cavity in an adult female patient with recurrent hematochezia, which should be considered in the differential diagnosis of the "doughnut" sign on radiological images.


The isolated superior mesenteric artery dissection (SMAD) is a rare and sporadic cause of acute abdominal pain. It most frequently affects male patients in their fifth to sixth decades, while our patient was a young woman who delivered a baby before the onset of abdominal pain. Possible risk factors for SMAD include hypertension, arteriosclerosis, abnormalities in elastic fibres, trauma, and pregnancy. In our case, delivery was suggested as a risk factor, which has not been reported previously.A 27-year-old woman complained of acute severe upper abdominal pain and vomiting for 2 days after delivery. The patient had no significant medical history. Physical examination revealed epigastric mild tenderness. All routine blood tests, blood coagulation analysis, liver function tests and abdomen computed tomography showed no remarkable findings. Computed tomography angiography revealed a marked dissection 3.5 cm below the superior mesenteric artery ostium. Since distal blood flow existed and the patient was in a puerperal state with no evidences of mesenteric ischemia, she was managed conservatively, including intestinal rest by fasting, parenteral nutritional support and antibioticis, without anticoagulants or antiplatelet agents. Fortunately, she recovered smoothly and had no recurrence.SMAD is a rare and sporadic cause of acute abdominal pain that occurs in young women after delivery. Isolated superior mesenteric artery dissection (SMAD) has been anecdotally reported as a rare and sporadic cause of acute abdominal pain, with an incidence of approximately 0.06% according to postmortem investigations . The majA 27-year-old woman was transferred to our hospital in October 2015 complaining of acute severe upper abdominal pain for 2 days after delivery of a baby, which was accompanied by vomiting and could not be relieved by acid suppression and antispasmodic treatments. The patient had no smoking habits, no hypertension history, no significant medical and family history except for delivery 2 days prior, which was not smooth and lasted for 23 h. Oxytocin was applied and forceps was not used. Hypertension peak during delivery was 130/80 mmHg. Physical examination revealed epigastric mild tenderness without any signs of peritonitis. All routine blood tests, blood coagulation analysis, liver function tests and computed tomography showed no remarkable findings. Thus, computed tomography angiography (CTA) was performed for further evaluation, which revealed a marked SMAD , CTA, MRI and angiography can all be used to diagnose SMAD; CTA , 20 is pThe management relies in: (1) conservative therapies including bowel rest, blood pressure control, oral/enteral antibiotics and parenteral nutritional support, with or without antithrombotic therapy; (2) the revascularization of viable intestine and (3) the surgical resection of necrotic bowel, based on symptoms, comorbidities, anatomic suitability, and physician’s preference . The admThe research  from MayIn conclusion, we report a case of SMAD that occurred in a young woman after childbirth and was cured by conservative means. Since SMAD can be recurrent , regular


A 20‐year‐old man presented in the Department of Urology, with the complaint of left‐sided lower abdominal lump for past 9 months. The patient denied of having any constitutional symptoms including weight loss. A 20‐year‐old man presented in the Department of Urology, with the complaint of left‐sided lower abdominal lump for past 9 months. The patient denied of having any constitutional symptoms including weight loss. Although seminoma is a common tumor of testis, occasionally it can be a diagnostic challenge! Typical histological pattern and immunoreactivity of the tumor cells play a pivotal role in the diagnosis of this tumor. The presented images provide the typical histomorphological features of seminoma and immunopositivity of the tumor cells.Physical examinations revealed a firm‐to‐hard, nontender, well‐defined mass in the left lower abdomino‐pelvic region with empty left scrotum. However, right scrotum was in situ position. MRI of pelvis showed an irregular, soft tissue mass measuring about 5 cm × 3 cm × 3 cm in the left pelvic region. This patient was diagnosed as a case of intra‐abdominal tumor in undescended left testis. The patient was operated with excision of the pelvic mass. Subsequently, the excised mass was examined in the Department of Pathology along with histological analysis.A conclusive diagnosis of seminoma requires meticulous histopathological and immunohistochemical analyses. Better understanding of the microscopy findings and the immunoreactivity of these tumor cells makes the diagnosis easier Figure There is no conflict of interest among the authors.NA: collected data and reviewed literature and wrote the manuscript. BPD: revised the manuscript and supervised.Hereby, I, Dr Nafisa Abedin consciously assure that for the manuscript, the following is fulfilled: 1) This material is the authors' own original work, which has not been previously published elsewhere. 2) The paper is not currently being considered for publication elsewhere. 3) The paper reflects the authors' own research and analysis in a truthful and complete manner. 4) The paper properly credits the meaningful contributions of co‐authors and coresearchers. 5) The results are appropriately placed in the context of prior and existing research. 6) All sources used are properly disclosed (correct citation). Literally copying of text must be indicated as such by using quotation marks and giving proper reference. 7) All authors have been personally and actively involved in substantial work leading to the paper and will take public responsibility for its content. The violation of the Ethical Statement rules may result in severe consequences. I agree with the above statements and declare that this submission follows the policies of Solid State Ionics as outlined in the Guide for Authors and in the Ethical Statement.


Heterotopic mesenteric ossification (HMO) is a rare condition that can be hereditary or nonhereditary. It can lead to small bowel obstruction, which may require corrective surgery. Most affected patients have a history of abdominal surgery or trauma. Spontaneously occurring HMO is even rarer, with only 7 cases reported till date. There has been no previous report of spontaneous peripancreatic HMO.A 60-year-old man presented with complaints of recurrent nausea and vomiting for 2 months. Esophagogastroduodenoscopy revealed luminal stenosis and edematous changes involving the second and third parts of the duodenum but not its complete obstruction. Abdominopelvic computed tomography showed faintly enhanced thickening of the involved duodenal walls along with mild dilatation of the common bile duct. Considering the possibility of periampullary cancer, we performed a pylorus-preserving pancreaticoduodenectomy. Histopathological examination confirmed the diagnosis of HMO with extensive fibrosis involving the peripancreatic soft tissue.The peripancreatic HMO with severe fibrosis can occur duodenal stenosis, and it is mimicking periampullary cancer. However, the preoperative diagnosis of spontaneous HMO is difficult, and a diagnosis confirmed after surgery.Herein, we described our experience of managing a rare case of duodenal stenosis due to spontaneous HMO involving peripancreatic tissue. There a2A 60-year-old man presented with complaints of recurrent nausea and vomiting for 2 months. No history of abdominal surgery or trauma was noted. There were no specific abnormalities in the laboratory analyses, carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9). Abdominal X-ray indicated a mildly distended stomach.We inserted a nasogastric tube and drained 50–300 ml of bile-stained gastric fluid for 3 days. After the stomach was fully decompressed, we performed an esophagogastroduodenoscopy (EGD), which showed both a large amount of bile fluid and food material in the stomach. The EGD further revealed luminal stenosis and edematous changes affecting the second and third parts of the duodenum, though the involved lumen was not obstructed completely A. ComputConsidering the possibility of cancer of either the pancreatic head or the periampullary region, we performed an exploratory laparotomy. Intraoperatively, we observed massive fibrosis and adhesions surrounding the second and third parts of the duodenum and the head of the pancreas. The entire pancreatic body was hardened, and the connective tissue around the head of the pancreas showed severe desmoplastic changes. We performed sophisticated adhesiolysis to release the duodenum along with a pylorus-preserving pancreaticoduodenectomy.The histopathology report confirmed the diagnosis of heterotopic ossification with extensive fibrosis of peripancreatic soft tissue. Grossly, we identified an ill-demarcated, dark-red-to-tan, soft, and fleshy lesion in the periampullary region A. Micros3This report highlights the case of a patient with spontaneous HMO, which is an extremely rare disease presentation that can involve the periampullary region and have diagnostic features that mimic those of pancreatic cancer.Heterotopic ossification (HO) is defined as the formation of bone in non-skeletal tissues and classified into 2 subgroups- hereditary and nonhereditary . NonhereIt is difficult to diagnose HMO preoperatively. However, detecting trabecular architecture and dystrophic calcifications on a CT scan may provide confirmatory evidence of ossification ,13. WhilIn HMO, surgical management is recommended, and recurrence is rare. As there are a few reports on the effectiveness of additional therapy for prevention of recurrence after surgery, further research is indicated in this regard ,3,12.4Spontaneous HMO involving peripancreatic tissue is rare disease. The peripancreatic HMO with severe fibrosis can occur duodenal stenosis, and it is mimicking periampullary cancer. However, the preoperative diagnosis of spontaneous HMO is difficult, and a diagnosis confirmed after surgery.The authors of this work have nothing to disclose.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This is a case report study and ethical approval not required.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor of this journal.Conceptualization: Hanlim Choi, Dong Hee Ryu.Data curation: Hanlim Choi, Chang Gok Woo, Ki Bae Kim.Investigation: Dong Hee Ryu.Supervision: Dong Hee Ryu, Jae-Woon Choi.Writing – original draft: Hanlim Choi.Writing – review & editing: Jae-Woon Choi, Dong Hee Ryu, Chang Gok Woo.Not applicable.The guarantor is Jae-Woon Choi.Not commissioned, externally peer-reviewed.


It is important to recognize that a prominent central canal of the spinal cord can be a normal variant and can spontaneously regress. A five-year-old male presented for evaluation of abnormal gait. Prior brain magnetic resonance imaging showed no hindbrain malformation, and the patient had no history of trauma. Full spine magnetic resonance imaging showed a vertical slit-like linear cavity within the center of the spinal cord, from C6-7 to the conus medullaris with a diameter ranging from 0.5 to 2 mm. This was initially reported as a syrinx. The patient’s symptoms remained stable. Three years later, follow-up magnetic resonance imaging showed spontaneous resolution of the slit-like cavity. This case likely represented a prominent central canal  that underwent normal closure. Hydromyelia is defined as the abnormal expansion of the central canal of the spinal cord. Syringomyelia is spinal cord parenchymal fluid accumulation off midline not lined with ependyma. The terms syrinx and syringohydromyelia can include either hydromyelia or syringomyelia. Prominent central canal is a more general term that does not necessarily imply pathology. Causes of syrinx include posterior fossa abnormalities  and trauma, though cases can be idiopathic. While there have been many cases of spontaneous regression of syrinx in the settings of posterior fossa abnormalities and trauma, few cases have been reported when the etiology was unknown. We present a case of a five-year-old male without posterior fossa abnormalities or a history of significant trauma, who had spontaneous resolution of a prominent central canal on a three-year follow-up. History was obtained from chart review. An institutional review board waiver was obtained. A four-year-old male, born at full term, initially presented for brain magnetic resonance imaging (MRI) without contrast to evaluate for developmental delay, autism, and attention-deficit/hyperactivity disorder (ADHD). Images showed non-specific asymmetric prominence of the right lateral ventricle. There were no posterior fossa abnormalities. At the age of five years, the patient presented for a full spine MRI without contrast to evaluate for abnormal gait. T2-weighted images revealed a prominent central canal from the lower cervical cord and extending caudally Figures -3. A fewThe central canal is patent in utero with most levels usually occluded by early adult life -3. An auThe differential diagnosis for fluid signal in the distal spinal cord includes ventriculus terminalis (VT), which is a cystic, ependyma-lined cavity in the central conus medullaris. It represents a normal embryologic structure that usually undergoes regression in utero, though it can sometimes be seen in neonates -5 and raThere have been a few reported cases of spontaneous resolution or near resolution of the syrinx or prominent central canal in the absence of trauma and hindbrain malformations Table . To our syringomyelia to avoid diagnostic confusion and patient and physician anxiety.Holly performed a retrospective analysis of 32 patients with focal slit-like syrinxes , who had long-term imaging follow-up (mean 38 months) and no hindbrain malformations . All patA persistent central canal is the result of delayed closure of the central canal of the spinal cord. We present a pediatric patient with a persistent central canal that underwent spontaneous normal closure, whose symptoms were unlikely to be related to the spinal imaging findings. Supporting the finding of a persistent central canal over a diagnosis of a syrinx, the canal diameter was consistently thin, and the patient did not have other findings to suggest altered CSF flow such as a hindbrain malformation. It is important to recognize that a prominent central canal can be a normal variant in order to avoid unnecessary anxiety, work-up, and intervention.


Basaloid follicular hamartoma (BFH) is a normally benign, uncommon, malformative lesion involving the hair follicles, which usually poses challenges in the differential diagnosis with other benign and malignant tumours, especially basal cell carcinoma, due to significant clinical and morphological overlap. Here, we report the case of a 53-year-old male who presented with a mass in the upper left eyelid evolving for one year. The patient had a previous history of total colectomy and an abdominal desmoid tumour within the context of Familial Adenomatous Polyposis (FAP), with a documented germline mutation in the Adenomatous Polyposis Coli (APC) gene. The eyelid lesion was biopsied and the histological analysis of the three small tissue fragments received revealed fragments with cutaneous–conjunctival lining displaying a subepithelial proliferation of basaloid nests with peripheral palisading, compatible with primitive hair follicles. There were images of anastomosis between different basaloid nests, which had their connection to the epithelial lining preserved. The stroma had high cellularity and sometimes primitive mesenchymal papillae were evident. Pleomorphism was absent, mitotic figures were barely identified, and no necrosis was seen. The basaloid nests did not have epithelial–stromal retraction nor mucin deposits. A diagnosis of BFH was proposed, which was later confirmed after surgical excision of the whole eyelid lesion. No evidence of carcinoma was present. This case illustrates the main features of the rare benign eyelid BFH. The standard medical or surgical approach of these lesions remains to be firmly established. Nearly nine months after surgical excision our patient remains well without signs of disease recurrence. Basaloid follicular hamartoma (BFH) is a rare benign lesion mainly consisting of a superficial malformation centred in the hair follicles . The lesWe report the case of a 53-year-old male who presented with a palpable 10 mm nodule in the upper left eyelid evolving for nearly one year, centred in the cutaneous-conjunctival transition area . The patThe eyelid lesion was biopsied by the ophthalmology team, and we received three elastic and whitish tissue fragments, measuring between 4 mm and 5 mm for those of the largest size. The histological analysis revealed fragments with cutaneous–conjunctival lining displaying a subepithelial proliferation of basaloid nests, with peripheral palisading, compatible with primitive hair follicles A,B. TherBFH is a rare benign malformative lesion involving the hair follicles, normally limited to the superficial dermis . There aBFH normally poses challenges in the differential diagnosis with other benign tumours of the follicular infundibulum  and malignant epithelial tumours, namely BCC, especially the infundibulocystic variant, due to significant morphologic overlap ,13. In oOur patient is a member of a FAP family. Interestingly, FAP patients carrying a germline APC gene mutation might develop several skin and soft tissue benign lesions, such as epidermal cysts, fibromas, desmoid fibromatosis, pilomatricomas, and lipomas ,17. HoweEven though BFH is typically considered a benign lesion, previous reports suggest that different forms of BCC could arise within the BFH context , which hNearly 9 months after surgical excision of the lesion, our patient remains well, without any signs of disease recurrence. The patient is being kept under an intensive follow-up plan for his other underlying medical conditions.We report here a solitary BFH arising in the lateral third of the upper left eyelid of a middle-aged male patient, who is a member of a FAP family. Reports of this typically benign basaloid tumour in the ocular region are scarce and, thus, it is important to document such cases to increase the awareness of the medical community to this disorder. This case illustrates the main features of this rare, non-malignant eyelid entity, which can display features analogous to other benign and malignant epithelial lesions, namely BCC, posing challenges to the accurate diagnosis. The potential of identifying malignant features within BFH has led to the precautionary recommendation of surgical excision in several cases. However, the gold standard medical or surgical approach of BFH remains elusive. A better understanding of the pathogenesis and natural evolution of BFH will help to establish in the future the optimal management approaches for these cases.


The presentation of congenital left atrial aneurysm is extremely rare in neonates. The neonate may suffer from severe respiratory distress symptoms, and by then, early surgical management is lifesaving. The presentation of congenital left atrial aneurysm is extremely rare in neonates. The neonate may suffer from severe respiratory distress symptoms, and by then, early surgical management is lifesaving. Even in asymptomatic cases, prompt surgical intervention is indicated to prevent fatal thromboembolic events such as stroke. In neonates and infants presenting early in life, surgical intervention is urgent to relieve respiratory distress symptoms. Herein, we introduce the case of a 3‐week‐old neonate who presented with severe respiratory distress symptoms. Diagnosis of congenital left atrial aneurysm was established and confirmed by transthoracic echocardiography and computed tomography angiography. The patient underwent surgical resection of the aneurysm using cardiopulmonary bypass and cardiac arrest. The patient was discharged from the hospital after 3 weeks with normal echocardiography.Congenital left atrial aneurysm (CLAA) is an extremely rare congenital cardiac anomaly with potential serious complications on long‐term basis such as arrhythmias, thromboembolic events, and myocardial dysfunction.2A 3‐week‐old neonate weighing 3400 g was brought to the emergency department of a pediatric hospital. The neonate has recently suffered from severe respiratory distress symptoms and was admitted and promptly intubated. Chest X‐ray (CXR) showed a well‐delineated (mass) on the left border of the heart extending to the left hemithorax compressing the left inferior pulmonary lobe Figure . TTE rev3Congenital left atrial aneurysm is a very rare entity in neonates with 70% of cases being left atrial appendage aneurysms, and the remainder are left atrial aneurysms.4Neonatal presentation of CLAA is extremely rare. Early surgical management is lifesaving in neonates with severe respiratory distress symptoms. Surgery for CLAA is safe and uncomplicated, with complete regression of the symptoms even in neonates.None declared.AA‐D: planned and performed the work leading to the report and wrote and reviewed successive versions and participated in their revisions. HA: wrote and reviewed the successive versions and participated in their revisions. SS: participated in writing the report and approved the final version.The manuscript was approved by ethics committee at Damascus University.


Background and Objectives: Periapical cystic lesions are a pathology frequently addressed to endodontic specialists. Although their therapy is still not standardized, the treatment should be as conservative as possible and by endodontic means, as they are lesions of endodontic origin. The present case report describes two cases of upper central incisors with large cyst-like periapical lesions, and their one-year follow up. Materials and Methods: Endodontic orthograde treatment was performed under copious irrigation with sodium hypochlorite, in association with calcium hydroxide as an intra-canal medication for both teeth. Root canal filling was achieved in a separate appointment using the continuous wave of condensation technique. A decompression procedure was used in association with endodontic therapy in the second case to reduce the pressure inside the cystic lesion and to allow its drainage, and only because the root canal could not be dried three weeks after medication. Initial cone beam computed tomography (CBCT) investigations, as well as at the one-year follow up, were used to compare the evolution of the lesion. Results: Both cases had a favorable outcome. New bone formation in the periapical region and complete resolution of the lesion was observed at the one-year control in the first case. In the second case, although the lesion was still not completely healed at 12 months, a significant reduction in its size could be observed, showing active signs of healing. Conclusions: Endodontic treatment is the first choice option in the management of teeth with pulpal necrosis and large periapical cystic-like lesions. Decompression is the only surgical procedure recommended when the canals cannot be dried and obturated. Large surgical interventions are unnecessary in cases where endodontic treatment can be performed. Radicular cysts are the most common odontogenic cystic lesions of inflammatory origin involving both the maxillary and the mandibular alveolar bone ,2,3,4,5.true cysts, with cavities that are completely encircled by an epithelial lining, and with no communication with the apical foramen; and bay cysts or pocket cysts, with epithelium-lined cavities which connect to the root canals  is effective against Gram-negative species and inactivates membrane transport mechanisms when performing its antibacterial functions [In addition, the use of calcium hydroxide as a root canal medication between sessions will increase the disinfection of the endodontic system by neutralizing the remaining microorganisms and will induce a favorable environment for periapical healing ,36,37. Munctions ,36. FurtIn both presented cases, calcium hydroxide was used in consideration of these factors and also for controlling the humidity from the root canal, it being known that one of the major problems of orthograde endodontic treatment is the impossibility of drying the root canal in large cystic lesions ,39,40,41The period of time required for the root canal medication to be effective varies from two weeks to six months ,36,40,41Moreover, by using ultrasonic activation of the solution, as in both described cases, the efficiency of the sodium hypochlorite could have been increased . Other mIn the second case, the calcium hydroxide medication was repeated after the first three weeks because the canal was still wet at the end of the procedure with all the supplementary means of irrigation, activation, and suction, and therefore the treatment was completed with a surgical decompression punction in the labial mucosa. The incision favored the drainage of the cystic lesion and also offered the clinician the possibility of observing the cholesterol granules in the exudate, which were a confirmation of its presumptive diagnosis. As the lesion showed active signs of infection with pus draining once the punction was created, metronidazole solution 5 mg/mL, an efficient antibacterial agent with rapid onset of action and efficiency against anaerobic bacteria, was used for irrigation ,46.Since histopathology is the only examination that confirms the real nature of periapical lesions, another advantage of using decompression punction is that it allows for a biopsy ,10,12. UIn comparison with periapical radiographs, CBCT examination allows more accurate measurements of the lesion limits in all three plans, the observation of its content, and also its direct relation to the root canal lumen ,48,49. WMoreover, the CBCT examination allows for a better quantification of the lesion size in comparison with periapical radiographs, establishing a more precise periapical index (PAI), the CBCTPAI ,48. MoreThe healing of all periapical lesions with bone destruction starts from the periphery of the defect towards its center, with size reduction caused by the new bone formation, as observed in both present cases. Radiologically, after a period of time, the lesion will appear smaller and bone trabecula will be observed with different radiopacities occupying the space of the former lesion. A complete healing, with a complete restoration of the periodontal ligament architecture on all root contours, can be observed at different periods of time, varying from one to four years ,50. In tA nonsurgical approach should always be adopted for the treatment of endodontic origin cystic lesions, even for the true type of cysts ,7,14,18.In both cases, the patients are asymptomatic and still under periodical observation, until the lesions are completely healed.Large cystic-like periapical lesions respond favorable to nonsurgical endodontic treatment. Although the evaluation period must be longer when taking into consideration the conservative management of these cases, the major advantages of performing endodontic therapy are represented by the minimally invasive procedures, with high rates of healing for the treated patients. Large surgical interventions are unnecessary in cases where endodontic treatment can be successfully performed.


To report 2 very rare cases of young women who presented with severe dysmenorrhea and a large cystic lesion in the myometrium, which presented a diagnostic dilemma because they were confused with a Müllerian anomaly.Case reports and a literature review.A university-based reproductive endocrinology and infertility clinic in the United States.An 18- and a 16-year-old nulliparous girl presented with worsening of their longstanding pelvic pain, and imaging study results were suggestive of a Müllerian anomaly.Abdominal and pelvic computed tomography, transvaginal ultrasonography, pelvic magnetic resonance imaging, operative laparoscopy, and excision of a juvenile cystic adenomyoma (JCA).Resolution of the pelvic pain and restoration of normal uterine anatomy after appropriate interventionRestoration of normal uterine anatomy, which was confirmed by 3-dimensional ultrasonography for case 1; however, case 2 still had a small remnant of JCA postoperatively.Clinical and radiologic examinations may not be useful in differentiating a Müllerian anomaly from other rare abnormalities like JCA. When in doubt, laparoscopy can assist in diagnosing and treating the condition. Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/posts/xfre-d-20-00248According to Bird et al. , adenomySecretory changes and menstrual bleeding within this heterotopic endometrial tissue can result in the formation of tiny hemorrhagic foci (<5 mm) within the myometrium. These foci are typically found in adult parous women of >30 years of age with global/diffuse adenomyosis. These small cysts can be seen as small myometrial cysts using ultrasonography and magnetic resonance imaging (MRI) . HoweverCystic forms of adenomyosis were first described by Cullen  in 1908 A retrospective chart review was performed for both the patients. To identify the previously published cases of JCA, a literature review, with PubMed and Google Scholar, was performed using various combinations of the following search terms: juvenile cystic adenomyoma, juvenile adenomyotic cysts, cystic myometrial lesions, accessory uterine cavity masses (ACUM), adenomyosis, Müllerian anomalies, noncommunicating uterine horn, and cavitated rudimentary uterine horn. Case reports of JCA were included if they met the following criteria: if they met the abovementioned criteria used to include a case as JCA, as described by Takeuchi et al. ; and adoAll cases reported were histopathologically confirmed JCA that presented with severe primary dysmenorrhea and a large, isolated cystic myometrial lesion revealed by pelvic imaging studies. Consent for this manuscript was obtained from both the patients.An 18-year-old nulligravida was referred to our clinic for gradually worsening pelvic pain and pelvic imaging result suggestive of a Müllerian anomaly. She started menarche at the age of 14 years. Her periods were always regular at an interval of 28 days and associated with severe dysmenorrhea, with pain starting before the menstrual period and continuing throughout the period. She was not sexually active. The patient underwent abdominal computed tomography (CT) and pelvic scans for the worsening pain, which reported findings consistent with those of bicornuate uterus versus uterine fibroids. She was started on hormonal therapy, with no relief of her symptoms. She subsequently underwent transvaginal ultrasonography, which showed a fluid-filled lesion on the left side of her uterus, concerning for a unicornuate uterus with a noncommunicating horn. Magnetic resonance imaging (performed in February 2016) confirmed these findings . No urogThe patient was referred to our clinic for worsening pelvic pain and imaging results suggestive of a Müllerian anomaly, with specific indication of a unicornuate uterus with a noncommunicating left horn. Three-dimensional transvaginal ultrasonography was performed at our clinic, showing a normally shaped endometrial cavity, endometrial thickness of 4 mm, and a separate 3 × 3-cm hypoechoic lesion in the left lateral myometrium that appeared to be distinct from the endometrial cavity.Given the inconclusive findings of the abovementioned imaging studies and the persistent pelvic pain, we recommended diagnostic laparoscopy with possible resection of the cystic mass. The patient gave informed consent before the procedure. The laparoscopy revealed a 3 × 3-cm uterine mass arising from the left lateral uterine wall and extending toward the left side of the broad ligament . Small fHistopathological examination of the cyst revealed benign smooth muscles with a decidualized endometrium, which was consistent with exogenous hormone therapy—consistent with a noncommunicating uterine horn instead of cystic endometriosis. Complete resolution of the myometrial cystic lesion and resumption of normal anatomy was noted postoperatively using transvaginal ultrasonography. Our patient is 21 years old now, relieved of her pelvic pain after the laparoscopic resection of the cystic adenomyoma. She has been prescribed continuous oral contraceptive pills for menstrual suppression.A 16-year-old nulligravid woman was referred to our clinic for the management of a cystic uterine lesion associated with acute worsening of chronic dysmenorrhea. She started menarche at the age of 14 years. Her periods were always regular at an interval of 28 days and associated with severe dysmenorrhea. She was prescribed oral contraceptive pills for dysmenorrhea, with partial relief. Before her referral to our clinic, she presented to the emergency room twice for worsening of pain in the lower quadrant. She underwent CT and ultrasound imaging, which revealed a cyst in the right lateral myometrium, consistent in its echotexture with that of an endometrioma. A CT of the abdomen and pelvis revealed a 4.7 × 3.8-cm subserosal cystic mass on the right side of the uterus, which appeared to be discrete from the endometrium. Pelvic ultrasonography was performed on the same day, which revealed a cystic lesion measuring 5.1 × 3.6 × 4.8 cm, with an echotexture consistent with that of an endometrioma, either within the cornua or in the fallopian tube; however, the exact location was difficult to identify using ultrasound.The patient underwent diagnostic laparoscopy, which confirmed a bulge arising from the right uterine cornua and the presence of a cystic mass, indicative of a Müllerian anomaly. Appendectomy was concurrently performed because of a rigid and hyperemic appearance of the appendix, and minimal endometriosis was fulgurated. She was referred to us for further care and worsening of the pelvic pain after she underwent the abovementioned laparoscopy. We performed laparoscopic excision of the uterine cyst following a procedure similar to that used for case 1. The intraoperative findings  were a 5Large myometrial cysts in young women are very infrequent. The most common presenting symptoms are severe dysmenorrhea and pelvic pain, with inadequate relief when typical medical management strategies such as nonsteroidal anti-inflammatory drugs and combined hormonal contraceptives meant for ovulation suppression are used.The etiology of juvenile cystic adenomyosis is not clear, although various investigators have proposed different theories in an attempt to identify the origin of these rare uterine abnormalities. Based on early-onset severe dysmenorrhea soon after menarche and the typical uterus-like organization of JCA, Takeda et al.  suggesteAlthough ultrasound remains the most common imaging modality for evaluation, MRI has also been shown to be useful in the evaluation of these cystic structures when they are not clearly defined using ultrasound. Using 3-dimensional transvaginal ultrasonography, a cystic adenomyoma can be visualized as a round cystic mass filled with hypoechoic content, separate from the normal uterine cavity, as seen in our first case, typically in the cornual region. On MRI images, cystic adenomyosis appears to be a well-circumscribed cystic lesion filled with hemorrhagic fluid in different stages of organization within the myometrium .Menstrual suppression using continuous oral contraceptive pills, gonadotropin-releasing hormone analogs, and nonsteroidal anti-inflammatory drugs may provide temporary and partial pain relief in JCA , 9, but Efforts to unfold the etiology of juvenile cystic adenomyosis can continue with better awareness of the condition and imaging modalities. Based on our comprehensive review of previous JCA cases , signifiBased on our experience and the literature review of JCA cases, we suggest that pelvic ultrasonography for young women with severe dysmenorrhea, performed transvaginally when appropriate and transabdominally in other patients, be considered the first diagnostic modality. When an initial imaging result does not lead to a clear diagnosis, MRI should be performed. Diagnostic laparoscopy should be offered when the diagnosis remains unclear after MRI or when dysmenorrhea is unresponsive to medical management. This also provides an opportunity for surgical management with mass resection, which might effectively help relieve symptoms.


The aim of the present article is to present the clinical case of a large peripheral ossifying fibroma that evolved from a previously diagnosed pyogenic granuloma in a 50-year-old woman. The patient was referred for treatment of a lesion over the buccal and palatal gingiva close to the left upper first molar. It was purplish-red in color, approximately 3 cm in diameter, having a smooth surface, a pedicled and bleeding base, with seven years of evolution, and diagnosed as pyogenic granuloma. After three years of evasion, the patient returned reporting an increase in the lesion and difficulty in eating. Clinically the nodule was lobular in appearance, pink in color and smooth, pediculated, firm in consistency, non-bleeding, about 5 cm in its greatest extension, extending to the maxillary tuberosity. The lesion was excised and referred for histopathological examination, which led to the diagnosis of peripheral ossifying fibroma. The patient was followed for approximately 18 months, prosthetically rehabilitated, with satisfactory healing and no clinical signs of recurrence.The possible evolution of a pyogenic granuloma to a peripheral ossifying fibroma was observed in this case, based on the histopathological changes that occurred, with the development of calcified material, fibrous maturation, and decreased vascular content of the initial lesion after three years. Pyogenic granuloma (PG) is the second most frequent reactive lesion of the oral cavity, after inflammatory fibrous hyperplasia, the most frequent reactive lesion. PG presents a well-circumscribed and distinct lobular arrangement, with large central vessels and well-formed peripheral capillary aggregates. When left untreated, this lesion can undergo fibrous maturation with ossification and develop into peripheral ossifying fibroma .Peripheral ossifying fibroma (POF) is a benign mesenchymal lesion, predominant in the anterior maxillary gingiva of women between the second and third decades of life. It is considered a metaplastic process that involves the periodontal ligament in response to trauma or local irritants, such as biofilm, calculus, poorly adapted prostheses, and unsatisfactory restorations ,3. The eThis report presents the case of a large peripheral ossifying fibroma that evolved from a lesion previously diagnosed as pyogenic granuloma in a 50-year-old woman.A 50-year-old hypertensive woman was referred to the Oral and Maxillofacial Surgery and Traumatology outpatient clinic of the Mato Grosso Cancer Hospital, Cuiabá, Brazil, for treatment of a maxillary lesion, diagnosed as PG, as demonstrated by the histopathological examination of an incisional biopsy performed previously. The microscopic description consisted of a fragment of mucosa covered by stratified hyperparakeratinized squamous epithelium, with areas of acanthosis and long projections, spongiosis, exocytosis, and ulceration. The lamina propria was formed by dense connective tissue, with areas of intense cellularity and proliferation of endothelial cells being noted, with opening of vascular spaces and regions of intense chronic inflammatory infiltrate with hemorrhagic areas Figure .Clinically, she presented a nodule over the buccal and palatal gingiva close to the left upper first molar, approximately 3 cm in diameter, with a smooth surface, purplish-red color, pedicled and bleeding base with seven years of evolution. In the referral, there was also the diagnosis of severe chronic periodontitis, observing, during the intraoral physical examination, poor oral hygiene and generalized tooth mobility.Due to the size and potential bleeding, in addition to the patient's medical history, it was decided to perform the excision of the lesion under general anesthesia, and to extract all teeth due to the degree of mobility and loss of bone insertion, aiming at further rehabilitation with total prosthesis.After three years of evasion, the patient returned reporting an increase in the lesion and difficulty in eating due to the trauma generated during chewing. Upon clinical examination, the nodule was lobular in appearance, pink in color and smooth, pediculated, firm in consistency, non-bleeding, about 5 cm in its greatest extension, inserted in the buccal and palatal gingival region of the left upper first molar, extending to the maxillary tuberosity. By this time, the duration of the symptoms was about 10 years Figure .The panoramic radiograph showed, in the area of the lesion, diffuse irregular radiopacity, with divergence of the crowns of the first and second molars, in addition to generalized loss of bone insertion Figure .The lesion was excised and the teeth were extracted under general anesthesia. The lesion, measuring approximately 5x4.5x3cm, was referred for histopathological examination, which led to the diagnosis of POF (Figure The histopathological report of the excised lesion revealed a fragment of mucosa covered by stratified keratinized squamous epithelium with long projections, exocytosis, and spongiosis. In the lamina propria formed by dense connective tissue, intense cellularity was noted, with elongated cells, formation of osteoid material, and intense mononuclear inflammatory infiltrate, with diagnosis of POF Figure .The patient has been followed for approximately 18 months, prosthetically rehabilitated with satisfactory healing and no clinical signs of recurrence Figure .We presented the case of a POF that had been diagnosed three years earlier as PG. POF and PG are reactive lesions of the oral cavity developed from low-intensity chronic irritation, stimulating an intense tissue repair response and producing increases in soft tissue volume .Clinically, the lesions have some distinctions: a POF is generally firm, pale pink to dark red, while a PG has a soft consistency, ranging from dark red to reddish purple, with a tendency to bleed easily ,7. As reDue to their clinical characteristics and common etiological factors, clinical differentiation between the lesions is difficult, requiring microscopic evaluation for a definitive diagnosis . HistopaAs discussed previously, the expression of osteopontin, a non-collagenous protein with high calcium binding potential, influencing tissue mineralization, is totally absent in normal oral mucosa, for example, but in some cases of PG there is expression in stromal cells and extracellular matrix, favoring the concept that PG can mature into POF. In comparison, there is expression of osteopontin in stromal cells, extracellular matrix, and in areas of ossification in all cases of POF . It is sThe presence of trauma or local irritants to cells of the periodontal ligament is identified as the etiology of POF. The occurrence exclusively in the gingiva, the proximity of the gingiva to the periodontal ligament, and the occurrence of oxitan fibers in the mineralized matrix support this etiological hypothesis ,4. In thPOF is prevalent in young patients and has a predilection for the female sex ; howeverSurgical excision is the treatment of choice, with peripheral and deep margins, in addition to the removal of the etiological agent. In gingival lesions, curettage of the underlying tissue is recommended. The recurrence of reactive lesions of the oral cavity is about 20% and is directly related to the failures in these maneuvers ,2,12. ThThe possible evolution of a PG to a POF was observed in this case based on the histopathological changes that occurred, with the development of calcified material, fibrous maturation, and decreased vascular content of the initial lesion after three years. Considering the reactive nature of the two lesions and biofilm and calculus as local irritants, oral hygiene guidance is as important as the recommended surgical treatment, thus minimizing the risk of recurrence.


This report provides a clinical, histological, and immunohistochemical description of an unusual hibernoma  in the subepidermal area of the nipple of a six-year-old bitch. Furthermore, an extensive literature review of hibernomas in animals was made. Physical examination revealed a nodular lesion in the subepidermal area of the third nipple of the left mammary chain. The histopathological findings included lobules of round to oval cells with abundant pale to eosinophilic cytoplasm, containing one or multiple optically empty vacuoles, consistent with nipple hibernoma. Immunohistochemically, the neoplastic cells were negative for cytokeratin AE1/AE3 and p53 but showed strong immunoreaction for vimentin and uncoupling protein-1, thus confirming the brown adipose tissue origin. Local recurrence was not detected after 18 months of follow-up. Hibernomas are rare and benign neoplastic lesions, originating from brown adipose tissue. Due to their histological and molecular resemblance with liposarcoma, a correct diagnosis of these neoplasms is required. In addition, the literature review suggests that hibernomas may present different features, according to species. Hibernomas are rare soft tissue benign neoplasms that originate in brown fat  . These tCurrently, there are several reported cases of hibernomas in veterinary medicine, mostly in the orbital region of dogs . In the Malassezia spp. that was further confirmed by cytology. Erythema and papular skin lesions were present on the abdomen. An additional nodular lesion was detected in the subepidermal area of the third nipple of the left mammary chain. The owner was aware of this lesion for at least 1 year before the dog was presented to the hospital, without causing any pain or discomfort to the animal. The dog was treated with corticosteroids  along with cleansing and topical application of Canaural® ear drops for the treatment of otitis externa. Excision of the mammary mass was advised and performed ~2 months later, after complete recovery of the dermatological signs.A six-year-old intact female mixed breed dog was presented with acute pruritus of ears, muzzle, and abdomen. The dog has been previously vaccinated and treated for both internal and external parasites. The physical examination revealed a decreased diameter of the auditory canal of the left ear with inflammation and brown granular content with a strong rancid odor, compatible with the overgrowth of The lesion was surgically removed, fixed in 10% neutral buffered formalin and submitted for histological examination.For histology, the samples were cut and processed routinely, and sections were stained with hematoxylin and eosin (HE) and periodic acid-Schiff (PAS). Immunohistochemistry was performed using the Novolink™ Max-Polymer detection system , employing the following monoclonal antisera: pan-cytokeratin  diluted 1:50; vimentin  diluted 1:100; uncoupling protein-1 (UCP1)  diluted 1:20 and p53  diluted 1:400. Positive controls consisted of sections of mouse perirenal adipose tissue  and caniGrossly, the tissue fragment was represented by a nipple, with an exophytic nodular and dense mass, measuring 12 mm × 6 mm × 4 mm. In cross-section, the lesion was well-delimited, partially encapsulated, with a homogenous appearance and white-yellow color.2)  . ScatterThe neoplastic cell population did not exhibit any immunoreactivity for cytokeratin AE1/AE3  and p53 Based on morphological, histochemical, and immunohistochemical findings, a diagnosis of a subepidermal nipple hibernoma was made.No local recurrence was detected after 18 months of follow-up.A hibernoma is a rare and benign soft tissue neoplasm of the brown adipose tissue (BAT). It was originally described and named “pseudolipoma” by Merkel, in 1906. In 1914, Gery Louis  derived BAT is present in both human and animal fetuses, being gradually replaced with white adipose tissue (WAT) with aging. However, it may persist in variable degrees throughout adult life, namely in the cervical and interscapular areas, axilla, mediastinum and periaortic and perirenal zones . In WAT,In veterinary medicine there are <20 reports of hibernomas in few animal species and in different anatomical sites . In dogsHerein, the tumor was peculiar not only for the associated anatomical site (nipple), but also for its superficial and subepidermal location. An identical lesion was described in 9-year old boy .In the majority of cases, hibernomas present as asymptomatic, painless, and slowly growing neoplasms, that are usually detected either as a palpable mass or as incidental imaging or necropsy findings, similarly to those occurring in humans . AccordiIn human medicine, six histological variants of hibernoma are described according to WHO classification: granular or eosinophilic, pale cell, lipoma-like, myxoid, spindle cell, and hybrid . Herein,Although complete surgical excision is advised to avoid recurrence, most authors claim that these neoplasms do not have the propensity for local recurrence or aggressive behavior. Once again, the existing bibliography seems to be consensual: all cases reported in dogs had benign features, regardless of the anatomical site or whether the surgical excision was complete; irregular and poorly defined boundaries, partial encapsulation, presence of cytological atypia and frequent mitosis, foci of necrosis and invasion of adjacent tissues and vessels are characteristics of malignancy mainly seen in rats. In specific cases, these features eventually led to potential paraneoplastic systemic manifestations, such as marked weight loss . Gadea eDifferential diagnosis that should be considered: residual or normal brown fat, which usually does not form a distinct mass; xanthogranulomatous (lipogranulomatous) inflammation, which normally presents with abundant foamy macrophages admixed with mature adipocytes and inflammatory and multinucleated giant cells, both foreign body and Touton types; classical lipoma, although adipocytes are not multivacuolated cells; lipoblastoma, normally composed of immature cells that resemble fetal adipose tissue in different development stages; and liposarcoma, which usually presents with infiltrative behavior, high cellular atypia and high mitotic activity.P53 overexpression was observed in two human lesions, leading to the hypothesis that functional inactivation of the protein product of this gene may be important in the development of these tumors . FurtherDespite the great abundance and long-life maintenance of the brown adipose tissue in animals, its neoplastic transformation appears to be a rarer event than in humans given the scarcity of cases reported in veterinary medicine. Additionally, following analysis of the existing literature, it was found that these neoplasms may present different features or behavior, according to species. Thus, a correct diagnosis as well as proper monitorization and documentation of hibernomas is needed in order to get insights into their putative metabolic impact, and to avoid unreasonable, radical therapeutic approaches and overtreatments.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the animal study because it was not the case.IA and FF contributed to the sample collection and performed the pathological studies and interpretation of the results. IA and CT analyzed the data and wrote the paper. MT and FF participated in immunohistochemical interpretation. FG contributed to the design, supervised the study, and helped to draft the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Cranial nerve palsies are commonly known comorbidities associated with nasopharyngeal carcinoma, occurring in nearly 20% of cases. These palsies occur in isolation or in common groupings, depending on the anterior or posterior cranial vault extension of the lesion. Cranial nerve VII palsy is relatively rare, with an incidence of less than 1%. As a poor marker of prognosis, cranial nerve involvement may lead to significant morbidity amongst patients with nasopharyngeal carcinoma.We report a case of a 73-year-old male diagnosed with nasopharyngeal carcinoma with extension into the skull base who presented with both anterior and posterior cranial nerve involvement throughout the course of his disease. With lesions in cranial nerves III, V, VI, VII, IX, and XII, this patient experienced a sequence of right-sided facial paralysis, facial pain, inability to abduct his right eye, rightward tongue deviation, tinnitus, hearing loss, decreased extraocular eye movement superiorly, and dysphagia which subsequently worsened with chemotherapy and radiation. Most notably, he presented with a right-sided cranial nerve VII palsy, not commonly reported in the literature. Nasopharyngeal carcinoma (NPC) is a historically rare malignancy with an incidence of less than one per 100,000 person-years and is most predominantly found in males indigenous to Southeast Asian countries .Usually, CN involvement due to NPC presents in either single palsies or in grouped CN syndromes, depending on the local spread of the tumor . CranialA 73-year-old Hispanic man with a medical history of hypertension, and type 2 diabetes mellitus presented to the emergency department (ED) with a chief complaint of right-sided facial pain, facial droop, and ptosis. Eight years prior, the patient had an episode of right-sided Bell’s palsy characterized by incomplete right-sided facial paralysis, which resolved spontaneously without any complications. The right facial and eyelid droop began two weeks prior to presenting to the ED while the severe, sharp, constant facial pain began one day prior to presentation prompting him to come to the ED. No other neurological findings were seen on physical exam and all laboratory results were within normal limits. The patient was discharged from the ED with a prescription of Percocet and advised to follow up with an outpatient neurologist for further work-up.One month later, the patient underwent a gadolinium-enhanced brain magnetic resonance imaging (MRI) which revealed an ill-defined infiltrating enhancing mass in the posterior right aspect of the nasopharynx with extension and infiltration of the skull base and was highly suspicious for a neoplasm Figure . The patOverall, pathology and imaging reports revealed the diagnosis of nasopharyngeal squamous cell carcinoma tumor, nodes, and metastases (TNM) staging: T3 N2 M0 Stage III with an extension of the mass to the adjacent structures both anteriorly and posteriorly. Additionally, there was evidence of both mass infiltration into the nasal cavity and locoregional metastasis into the neck lymph nodes bilaterally. The tumor was also found in the skull base region with erosion and interarticular extension into sphenoid sinuses bilaterally. The outpatient otolaryngologist determined that this patient was not a candidate for surgical resection and would follow up with oncology for chemotherapy and radiation. Further explanation of surgical versus medical treatment for NPC will be outlined in the discussion.One month following definitive diagnosis, the patient presented to the ED prior to initiating chemotherapy and radiation treatment with new onset of severe headaches, tinnitus, facial paresthesias, dysphagia, nausea, and vomiting. He continued to present with the symptoms on initial presentation of right-sided facial pain, droop, and ptosis. He also reported losing 40 pounds in three months and inability to swallow solid foods. With suspected involvement of CN IX and new-onset headaches, CT imaging was performed which reported stability of the nasopharyngeal mass without any acute intracranial hemorrhages or midline shifts. He was given Tylenol for pain and advised to report to outpatient oncology to initiate treatment.Five days following his first chemotherapy and radiation session, the patient presented to the ED with severe fatigue, dehydration, worsening dysphagia, and odynophagia. The patient was only consuming liquid meal replacements three times daily due to dysphagia for the past three months. Physical exam revealed consistent CN findings with documentation of decreased upward gaze when examining EOMs, suggestive of CN III involvement. Laboratory studies showed signs of dehydration secondary to poor oral intake including hyponatremia (131 mmol/L), hypokalemia (3.3 mmol/L), and hypochloremia (95 mmol/L), acute kidney injury (AKI) with significant elevation in blood urea nitrogen (BUN), and creatinine from baseline values within normal limits to 34 mg/dL and 1.99 mg/dL, respectively, The patient was initiated on intravenous (IV) fluids and gastroenterology was consulted for percutaneous endoscopic gastrostomy (PEG) tube placement due to severe dysphagia. Following resolution of electrolyte imbalance and AKI, the PEG tube was surgically inserted and tube feeding with Neutron was started. The patient reported significant improvement in fatigue, tolerated bolus feeding without nausea, vomiting, or abdominal pain, and was advised to follow up with an outpatient oncologist following discharge. This is a case of a T3 N2 M0 staged squamous cell NPC with significant expansion into the neighboring structures of the nasopharynx and cervical lymph nodes. Generally, surgical resection does not play a large role in the initial treatment for NPC regardless of the staging, with chemoradiotherapy serving as the gold standard . AdditioCN palsies are found in approximately 20% of NPC cases and may clue physicians into working up the possible diagnosis of locally invasive NPC . Common In this case, the patient presented with CN V dysfunction as evident by the trigeminal neuralgia experienced throughout all clinical presentations. The patient’s pain traversed all three branches of CN V on physical exam, consistent with probable tumor extension into the superior orbital fissure, foramen rotundum, and foramen ovale. The involvement of CNs III and VI were also evident in the patient, completing a clinical picture similar to superior orbital fissure syndrome that has been described in the literature . This haIsolated involvement of CN VII has not been widely reported as an initial clinical manifestation of NPC and may occur in less than 1% of patients with NPC . Three pThis is the only case reported of NPC involving a sequence of symptoms associated with CN III, V, VI, VII, IX, XII that has been reported in the literature. Additionally, the involvement of CN VII makes this case particularly unique. Since this type of neoplasm does not warrant immediate surgical resection and there was a three-month difference between diagnosis and treatment, the mass continued to compress structures, leading to the progression of symptoms. With CN involvement being associated as a poor prognostic indicator for NPC disease progression, we concluded that thorough and frequent neurological examinations are warranted throughout the treatment course with NPC patients.


Mediastinal masses always present a diagnostic challenge to clinicians and radiologists. There are wide varieties of pathologies ranging from benign to malignant conditions. Teratomas are one of the rare causes of mediastinal tumors. In this case, we report a young male who presented to the emergency room with acute pleuritic chest pain. The chest X-ray showed massive right-sided pleural effusion. Subsequently, bedside chest ultrasound ruled out septations and helped drain the fluid. The pleural fluid analysis demonstrated transudate chemistry. A computerized tomography (CT) of the chest was performed, revealing a complex anterior mediastinal mass suspected of Mature Teratoma. The tumor was surgically removed in its entirety, and pathology confirmed it a mature teratoma. The patient remained asymptomatic on postoperative follow-up. Teratomas are germ cell tumors with well-differentiated tissues from all three embryonic layers. They are generally gonadal in origin yet can seldom arise from tissues outside gonads and are termed “Extra-gonadal Teratomas”. The mediastinum is the most well-known extra-gonadal site, and the majority of the teratomas at this location are benign. Teratomas are more common in the young population and have equal gender distribution. Mostly they are asymptomatic, but sometimes they present with symptoms from compression of surrounding structures. Pleural effusion is a rare presentation of mature teratoma with only a few case reports in the literature.A 25-year-old male presented to the emergency department (ED) with a two-day history of right pleuritic chest pain. The pain was in the centre of the chest and non-radiating. It was gradual in onset, dull in character, and 2/10 in intensity. There were no aggravating or alleviating factors. Furthermore, there was a history of worsening shortness of breath over a period of five months. The patient also complained of orthopnea needing two pillows but without paroxysmal nocturnal dyspnea. The patient declined a history of cough, fever, rigors, chills or hemoptysis. The patient also denied any history of recent travel, legs swelling or pain. There was no history of skin rash, joint pain or frothy urine and no history of trauma to the chest. He had a good appetite, and his weight remained stable over time. The patient was a university student and had no history of exposure to industrial fumes or dust; specifically, there was no history of asbestos exposure. He was a light smoker with a history of fewer than five packs a year. There was no family history of lung disorders or malignancy. Past medical history was unremarkable.On initial assessment in ED, he was comfortable while sitting. Observations were normal with blood pressure 110/70 mmHg, heart rate 95 beats per minute (bpm), respiratory rate (RR) 16, and saturation of oxygen (O2) 95% on room air. He was afebrile with a temperature of 36.8˚C. There was no clubbing or lymphadenopathy.He had decreased breath sounds at the right base on chest examination with a stony dull percussion note. Cardiovascular examination was normal. Moreover, there were no palpable abnormalities in the bilateral testis. The rest of the systemic examination was normal.His baseline blood investigations, as shown in Table X-ray chest Figure  showed mWe performed a bedside ultrasound of the chest to rule out septations, which were absent. Therefore, he underwent pleural drainage to relieve shortness of breath. The pleural fluid analysis was consistent with transudate Table Post drainage X-ray chest Figure  showed pWe did a CT chest Figures , 4 whichMoreover, there was a possibility that a significant proportion of the right hemithorax fluid on radiographs was part of the cystic extension of the anterior mediastinal lesion. Additionally, tumor markers as shown in Table The patient underwent a CT-guided biopsy, but the sample was not enough to make a diagnosis. Subsequently, the patient underwent an excisional biopsy of the mass on multidisciplinary team advice. On the pathological analysis, macroscopically, the tissue sample was well-demarcated approximately 16 x 6 x 13 cm in size and partially encapsulated. Cut sections exhibited irregular arrangement of solid and cystic areas of varying colour and size, including mucoid cysts. Moreover, microscopically, the sections revealed a mature teratoma comprising mature elements, including salivary gland Figure , gastroiThe patient was followed up in the clinic after six weeks postoperatively and remained asymptomatic. Complete surgical removal of mature teratoma is almost always curative and does not require prolonged follow-up; therefore, the patient was discharged from the clinic.The “teratoma” word originated from the Greek word “teras”, meaning monsters. Teratomas are types of germ cell tumors composed of tissues derived from all three embryonic layers, namely ectoderm, mesoderm and endoderm. They may arise from gonads (ovaries or testes) or maybe extra-gonadal with no primary tumor in ovaries and testes . The antThe exact pathogenesis for the extra-gonadal location of germ cell tumors is unknown. However, a plausible mechanism would be the failure to migrate germ cells to gonadal ridges during embryologic development . AlternaGenerally, teratomas are divided into mature and immature types. Mature teratomas are benign and have equal gender distribution. Immature teratomas, on the other hand, are almost always malignant and exclusively found in males. Mediastinal teratomas are frequently asymptomatic and found incidentally on chest imaging . If presPleural effusion is rarely seen with teratomas and is only limited to case reports. Moreover, no elucidated data is available regarding the nature of pleural fluid related to teratoma. In our case, effusion was transudative, but in the absence of any obvious etiology and right paratracheal stripe thickening, we decided to do a CT chest that confirmed and characterized anterior mediastinal mass. Later the biopsy established the diagnosis of mature teratoma.Chest X-ray may show well-defined anterior mediastinal mass with calcification present in 26% of mature teratoma cases . The preCT scan is the investigation of choice, which can accurately locate the mass and characterize different densities within the mass. CT scan can also delineate the relationship with the surrounding structures. The MRI is more helpful to look for the invasion of surrounding structures or in cases of thoracic inlet or thoracoabdominal location of the tumor . Tumor mDifferential diagnosis of mediastinal teratomas is vast, usually comprising Thymomas, thyroidal masses, lymphoma and extra-gonadal teratoma. Imaging can help differentiate these masses, but it is prudent to take a tissue biopsy to confirm the diagnosis. Thymomas are usually unilateral with well-defined smooth margins. Microscopically they are composed of lobules of neoplastic epithelial cells and reactive lymphocytes, intersected by fibrous bands. Additionally, they may contain fatty tissue, in which case they are named thymolipomas. Lymphomas present as a diffuse mass, which usually encase mediastinal vessels and have varied histology depending on the type. Thyroidal masses  usually appear as a continuation of thyroid tissue from the neck, and they may show calcification. On the other hand, teratomas usually exhibit heterogeneous mass with a characteristic display of variable amounts of fat, fluid, soft tissue and intralesional calcification. Intralesional fat is present more frequently; however, fluid that has higher specificity is seen only in fewer cases.Surgical removal of mediastinal mature teratoma is almost always curative; however, any immature component requires chemotherapy. Mature Teratomas have an excellent prognosis. However, it is vital to make sure that there is no immature component in histopathology. In a study including 45 cases of mature Teratomas, surgical removal resulted in a cure in all the patients .Mediastinal mature teratoma is a rare and benign condition. Most patients are asymptomatic and rarely present as pleural effusion. Characteristic findings on CT scan and MRI point towards the diagnosis and determine the extent of the disease. The biopsy confirms the diagnosis and rules out any immature elements, which may indicate cancer. In patients with no obvious pathology for pleural effusion, it is prudent to consider teratoma as a potential diagnosis, even if the effusion is transudate. Mature teratoma can be cured by surgical removal.


Intestinal intramural hematomas are a rare complication of blunt abdominal trauma in the setting of anticoagulation. A 52-year-old male presented to our surgical service with high-grade small bowel obstruction secondary to an extensive small bowel intramural hematoma requiring resection. The patient sustained a blunt abdominal assault several days earlier and workup revealed severe coagulopathy likely secondary to overexposure to a warfarin-based substance. Few cases have been reported on coagulopathic traumatic small bowel hematomas causing small bowel obstruction. Current literature suggests non-operative management can be used safely; however, operative intervention is warranted if there are signs of ischemia or perforation. This case highlights the importance of a high index of suspicion, thorough investigation, and prompt intervention to avoid significant morbidity in small bowel obstruction secondary to intramural traumatic hematoma. Intestinal intramural hematomas are caused by rupture of the terminal artery that arises from the mesentery and penetrates into the muscular layer of the intestinal wall. Bleeding within this space causes dissection of the muscularis mucosa and muscular layers ,2. As thSpontaneous small intestine intramural hematoma is a rare complication of anticoagulant use, reported to occur in about one case per 2500 patients on anticoagulant therapy per year . ConversThe patient is a 52-year-old incarcerated male with a past medical history of diabetes mellitus, chronic pancreatitis, and remote history of open cholecystectomy who was transferred to the hospital for complaint of abdominal pain. He reported three days of worsening epigastric and periumbilical abdominal pain with associated nausea and obstipation. He also reported two days of hematuria without dysuria or frequency. Four days prior, he was awakened by another prisoner who was kicking him in the abdomen.On presentation, he was tachycardic but normotensive. His abdomen was distended and diffusely tender. Initial lab work was notable for leukocytosis of 17 and significant coagulopathy with an unmeasurable international normalized ratio (INR), partial thromboplastin time (PTT) > 200, and prothrombin time (PT) > 120. Repeat labs confirmed the coagulopathy. He denied any ingestions or known exposures. He was given two units of fresh-frozen plasma (FFP) as well as vitamin K and his coagulopathy began to correct.A CT scan of the abdomen/pelvis revealed significant bowel dilatation with mural edema and thickened loops of jejunum Figure . There wHis post-operative labs were notable for a normalizing INR of 1.4 and PTT of 30. Given the unclear etiology for his extreme coagulopathy, Hematology was consulted. He had no family history of coagulopathies or hematologic disorders. He reported no history of bleeding symptoms prior to this episode. Coagulation studies were consistent with a deficiency of vitamin K dependent clotting factors that corrected with mixing studies. Differential diagnosis included common pathway factor deficiency, inhibitor exposure, or false result. Disseminated intravascular coagulation (DIC) and liver failure were ruled out. As his coagulopathy quickly corrected with FFP and vitamin K, the most likely etiology was exposure to overdose of a warfarin-based substance. He received additional vitamin K and recovery was otherwise unremarkable. Hematuria had resolved with correction of the coagulopathy. He was discharged on the seventh post-operative day to the prison infirmary. The final pathology was notable for portion of small intestine with transmural hemorrhage with clear resection margins.There have been numerous reports of spontaneous intramural hematomas secondary to anticoagulant use . These cDue to the uncommon presentation, there is no evidence-based literature suggesting standardized treatment . Most stLikewise, in the case of blunt abdominal trauma, bowel and mesenteric injuries are uncommon presentations, reportedly found in 3%-5% of patients . Often, Intramural hemorrhage in blunt abdominal trauma often occurs in the duodenum ,17. ThisThis case highlights a rare case of both anticoagulant overexposure and blunt abdominal trauma leading to small bowel obstruction. It should be noted that the diagnosis of intestinal hematoma was not correctly identified on the preoperative CT scan. The extensive nature of his small bowel hematoma suggests that his hematoma occurred due to his extreme coagulopathy in conjunction with blunt abdominal assault. The length of small bowel involved is not common in traumatic injuries alone nor spontaneous bleeds . The extWe present a rare case of multifactorial small bowel hematoma causing obstruction. Spontaneous intramural hematoma on anticoagulation and blunt abdominal trauma are both rare etiologies for bowel obstruction. This case highlights the importance of a high index of suspicion, thorough investigation, and prompt intervention to avoid significant morbidity in small bowel obstruction.