Endometriosis refers to the implantation and proliferation of endometrial tissue outside the uterus. Small bowel endometriosis is an uncommon location for endometrial deposits and when present, it can pose diagnostic difficulty. Here, we present a case of a 50-year-old female with small bowel endometriosis who suffered from recurrent attacks of colicky abdominal pain for few months. Her cross-sectional investigations remained largely inconclusive. Ultimately, she underwent diagnostic laparoscopy which was diagnostic and therapeutic. Endometriosis is an important cause of chronic abdominal pain in women of childbearing age. It refers to the implantation and proliferation of functional endometrial tissue outside the uterus . ReporteBowel endometriosis may be entirely asymptomatic. However, it may cause a constellation of symptoms such as nausea, vomiting, recurrent colicky abdominal pain, rectal pain, mass formation, and rarely intestinal obstruction . Recto sIn this report, we are presenting a case of symptomatic ileal endometriosis necessitating bowel resection. The patient underwent multiple investigations without a definitive diagnosis. She eventually underwent diagnostic laparoscopy. Surgical findings were consistent with endometriosis of the small bowel which was later confirmed on histology. This report serves as a reminder that small bowel endometriosis is a significant cause of chronic abdominal pain which may initially be overlooked. Therefore, when present, it may present a unique diagnostic challenge.A 50-year-old female was referred to a surgical clinic with troublesome recurrent abdominal pain for few months, few episodes of which had culminated in acute hospital admission. The pain was spasmodic in nature and associated with vomiting. She also described rectal bleeding and diarrhoea on a few occasions. Her history included a laparoscopy for diagnosis and treatment of pelvic endometriosis. She also underwent endometrial ablation for menorrhagia a few years ago.Her abdomen was soft and non-tender, with no obvious masses or organomegaly. Her lab workup did not show any abnormality, she had normal hemoglobin (Hb) of 136 g/L (115-165 g/L), urea 5.5 mmol/L (2.5-7.8 mmol/L), and creatinine 65 µmol/L (45-84 µmol/L). Her faecal analysis was also unremarkable. She underwent a contrast-enhanced CT scan abdomen/pelvis, which did not show any abnormality. Also, a full colonoscopy was carried out, which did not show any anomaly.Her MRI abdomen demonstrated an area of abnormal perienteric thickening in the distal ileum raising the possibility of either a Meckel's diverticulum or endometrial deposit. It was followed up by a small bowel MRI which remained equivocal, however, suggested that if thickened small bowel was just a tortuous small bowel loop Figure .The patient also underwent a Technetium-99m (99mTc) nuclear medicine Meckel's scan, which interestingly showed an area of tracer uptake and suggested the possibility of Meckel's diverticulum Figure .After a complete set of investigations, the patient underwent diagnostic laparoscopy, which demonstrated a distal small bowel mesenteric lesion causing kinking of the small bowel. Upon release, a chocolate-colored fluid was noted from the lesion. The involved small bowel was resected, and a side to side anastomosis was fashioned. The small bowel was thoroughly looked for the presence of Meckel's diverticulum, which was not present. Histology results were consistent with an endometrial deposit of the small bowel, and no other abnormality was found Figure .Post-operatively, the patient has made a good recovery and remains symptoms-free to date.The exact aetiology of endometriosis remains unclear. However, certain theories have been proposed to elucidate their origin. One such theory is Sampsons' theory of retrograde menstruation: which suggests that during menstruation, endometrial tissue emigrates through the fallopian tube to form serosal deposits on abdominal and pelvic organs ,6. AlterEndometrial tissue, regardless of its location, is hormone-responsive and can proliferate to form cysts and nodules, which can cause chronic pain, bleeding, and scarring -10. The Small bowel endometriosis is thought to affect serosa, and deposits tend to be less than 2 cm. In most cases, it is asymptomatic; however, it may lead to chronic inflammation leading to fibrosis, which successively accounts for most of the gastrointestinal tract symptoms. However, the transmural spread has also been observed, resulting in rectal bleeding, bowel obstruction, and mass formation mimicking tumors . Rarely,It can be challenging to diagnose bowel endometriosis in a timely and precise manner, as was the case with our patient. However, bowel endometriosis is to be suspected in otherwise fit and well young female patients, especially when there is a history of concomitant pelvic endometriosis.CT scan can help identify a thickened, stenosing mass; however, it is rarely diagnostic of endometrial deposits. A contrast-enhanced CT scan in our patient did not demonstrate any abnormality in the small bowel. Multislice CT, however, when combined with enteroclysis (MSCTe), has a high potential for detecting alterations in the intestinal wall. In a study of 98 women with symptoms indicative of colorectal endometriosis, Biscaldi et al. found that MSCTe reported 94.8% of bowel endometriotic nodules .Since endometrial tissue involves the deeper layers of the abdominal wall, endoscopic biopsies may yield insufficient information required for diagnosis. When bowel mucosa is involved with endometriosis, it may result in a non-specific pattern of inflammation; therefore, it can be challenging to differentiate it from other forms of bowel disease such as ischemic colitis or inflammatory bowel disease .Magnetic resonance imaging has high sensitivity in diagnosing endometriosis (77-93%). MRI has also been concomitantly used with rectal ultrasound. Sensitivity and negative predictive value of rectal ultrasound range from 92% to 100%. However, it has poor specificity and positive predictive values, 66% and 83-94% ,17.In our patient, MRI raised a possibility of thickened bowel loop in distal small bowel suggestive of either a Meckel's diverticulum or an endometrial deposit. It was followed up by a nuclear medicine Meckel's scan, which showed tracer uptake at the level of mid to distal ileum suggestive of Meckel's diverticulum.Diagnostic laparoscopy and biopsy remain the gold standard treatment in suspected endometrial deposits of the bowel wall. It allows visualization of abdominal and pelvic organs and allows resection if required . In the There are surgical and medical approaches to the treatment of endometriosis. The surgical approach allows the correct diagnosis and treatment at the same time in cases where a diagnosis has not been obtained with confidence pre-operatively. Whereas a medical approach can be utilized to treat confirmed cases of bowel endometriosis which are not causing obstructive symptoms. Few drugs have been proven to reduce the size and symptoms of endometriosis effectively; these include nonsteroidal anti-inflammatory drugs (NSAIDs) combined with oral contraceptives, aromatase inhibitors, and gonadotropin-releasing hormone agonists. These drugs function by reducing inflammation, suppressing or interrupting ovarian hormone development, resulting in hypoestrogenic conditions and endometrial atrophy ,20.The severity and clinical appearance of intestinal endometriosis determine the surgical approach. Patients with small deposits can be offered medical treatment first, with elective resection scheduled later. On the other hand, resection of the affected bowel is needed for large lesions causing an imminent obstruction. Surgical management was utilized as a diagnostic and therapeutic approach in our patients.Even though various imaging modalities are readily available to aid in the diagnosis of bowel endometriosis, it can still be challenging to diagnose it and be mistaken for other diseases. The possibility of intestinal endometriosis should be carefully considered, particularly in young female patients with a history of endometriosis elsewhere in the body. Laparoscopy remains the gold standard diagnostic and therapeutic approach.


Epidermoid cysts are benign cystic lesions that are usually found in the skin. They can also be found in the organs of the gastrointestinal system. Here, we report a rare case of epidermoid cyst of the appendix which has been published in only three cases in the literature. They can be either congenital or acquired. Congenital epidermoid cysts are related to the inclusion of ectodermal elements at the time of neural groove closure. Acquired cysts are thought to be due to trauma or iatrogenic implantation of the epidermis in locations favorable to growth during surgery. Diagnosis is mainly by histopathological examination of the tissue sample. Complete excision of the cyst with the walls intact is considered curative.  Epidermoid cysts are benign cystic lesions that are usually found in the skin. They are most commonly located on the face, neck, and trunk . They haA 34-year-old gentleman with a past medical history of hypertension, hyperlipidemia, obstructive sleep apnea presented with a one-week history of abdominal pain. The pain started in the periumbilical region and radiated to right lower quadrant. It was associated with anorexia, nausea and diarrhea. There was no history of abdominal trauma or surgery. Physical examination was significant for right lower quadrant and suprapubic tenderness. There was no fever or leukocytosis. Computed Tomography (CT) scan of the abdomen and pelvis revealed a dilated appendix with peri-appendiceal fat stranding, thickening of adjacent peritoneal reflection and multiple enlarged mesenteric and pericolic lymph nodes. With the diagnosis of acute appendicitis, laparoscopic appendectomy was performed. On gross examination, the appendix was dilated at 10 mm in diameter. The serosa was tan-pink and focally smooth with scattered adhesions and tan-white exudate-like material at the junction of the serosa and the appendiceal fat. The mucosa was firm and tan-white, with an average wall thickness of 1 mm. No fecaliths or obvious transmural perforation sites were appreciated grossly. There was a benign cystic lesion that was removed and sent for biopsy. Histopathological examination revealed cyst wall lined by squamous epithelium Figure . The finAn epidermoid cyst is a benign encapsulated, subepidermal nodule filled with keratin material . It is aEpidermoid cysts in the appendix are unique pathology with only three cases published in the literature. It can present as asymptomatic abdominal mass as well as acute abdominal pain. Although it is benign and rare entity, clinician should have high index of suspicion for this diagnosis since it can present as an acute abdomen.


Angiosarcomas are rare malignant tumors that arise from the endothelium of blood vessels. They occur most commonly in the skin and soft tissue, and less commonly in the breast, liver, bone, and spleen. Gastrointestinal angiosarcomas are extremely rare. Herein, we present a case of duodenal epithelioid angiosarcoma that was treated with surgical resection.A 68-year-old man presented with a 1-month history of fatigue and hypotension. He visited the outpatient clinic for a routine follow-up. Laboratory examination revealed anemia. Esophagogastroduodenoscopy revealed multiple duodenal lesions with central ulceration. A biopsy showed a sheet-like arrangement of large round and spindle-shaped tumor cells that were positive for CD31. Based on the histological and immunohistochemical staining findings, an epithelioid angiosarcoma was diagnosed. Computed tomography (CT) and positron emission tomography–CT revealed no lymph node metastasis or distant metastasis. Radical subtotal stomach-preserving pancreatoduodenectomy with lymphadenectomy was performed. After removing the specimen, reconstruction was performed using the Child procedure. Grossly, two dark-red polypoid tumors were found in the second portion of the duodenum. Histological evaluation revealed proliferation of malignant round and polygonal cells arranged in sheets and spindle-like cells arranged in bundles. Vasoformative structures were recognized as slit-like spaces containing red blood cells. Immunohistochemical staining demonstrated that the tumor cells were positive for CD31. These findings confirmed the diagnosis of epithelioid angiosarcoma in the duodenum. The patient’s postoperative course was uneventful. The patient was discharged on postoperative day 19 without any complications. At a follow-up examination in the outpatient clinic at postoperative 4 months, no evidence of recurrence was detected.The present report describes a case of duodenal epithelioid angiosarcoma. Duodenal angiosarcomas may cause anemia and gastrointestinal bleeding. Because angiosarcomas sometimes show epithelioid cytomorphology, immunohistochemical analysis is useful for confirming the diagnosis. Angiosarcomas are rare malignant tumors that arise from the endothelium of blood vessels. These tumors account for 1–2% of all soft tissue sarcomas [A 68-year-old man presented with a 1-month history of fatigue and hypotension. He underwent aortic root replacement for annuloaortic ectasia 9 years prior and underwent omentum patch repair for sternal osteomyelitis after sternotomy. He had a medical history of essential hypertension and pneumoconiosis. He took aspirin, warfarin, some hypertensive drugs, and proton pump inhibiter. He visited the outpatient clinic for a routine follow-up. Laboratory investigation showed a hemoglobin level of 8.7 g/dL, a significant decrease compared with the previous value of 15.2 g/dL. After he was documented anemia, he stopped to take warfarin and continued to take aspirin for antithrombotic drugs due to cardiac surgeon’s decision. Esophagogastroduodenoscopy (EDGS) revealed multiple duodenal lesions with raised red borders and central depressed areas. The anal side tumor was elevated lesions with central depressed area (Fig. no. 5, 6, 8a, 8p, 12a, 12p, 12b, 13a, 14p, 17a lymph nodes [Exploratory abdominal surgery revealed no peritoneal metastases. The omentum, which was patched to the sternum, was adherent to the liver. Adhesiolysis of the upper abdominal cavity was initially performed, followed by radical subtotal stomach-preserving pancreatoduodenectomy with lymphadenectomy. We dissected Grossly, two dark-red polypoid tumors were found in the second portion of the duodenum. The gross appearance was slightly different from EGDS findings. The anal side tumor, measuring 1.0 × 1.0 cm, showed erosion, and the oral side tumor, measuring 1.4 × 0.9 cm, was ulceration Fig. b. The leAngiosarcoma is a rare form of malignant connective tissue neoplasm that arises from the endothelial cells of blood vessels. Tumors can arise in any part of the body, and many cases are seen on the skin of the head and neck region. Intra-abdominal angiosarcomas are rare, and the spleen and liver are the most commonly associated organs. The gastrointestinal tract is an extremely rare site for angiosarcoma. To the best of our knowledge, only five cases of primary duodenal angiosarcoma have been reported so far –8. In thClinically, angiosarcomas can present with various symptoms depending on their primary location. In most cases of gastrointestinal angiosarcoma, the symptoms are nonspecific, including gastrointestinal bleeding, abdominal pain, intestinal obstruction, abdominal distention, weight loss, shortness of breath, anemia, and weakness . AlthougThe histologic features of angiosarcoma show a wide spectrum of appearances, ranging from clear vasoformative to poorly differentiated solid tumors in which the vascular nature is not readily apparent. Some angiosarcomas demonstrate epithelioid cytomorphology. Epithelioid angiosarcoma is composed of solid sheets of large, oval, or rounded epithelioid cells with abundant eosinophilic or amphophilic cytoplasm and a large, pale vesicular nucleus with a conspicuous eosinophilic nucleolus . HoweverAngiosarcomas are known for their rapid proliferation, aggressive infiltration, hematogenous metastasis, and relatively poor prognosis with low life expectancy. The 5-year survival rate is 31–40% with a median overall survival of 16–31 months , 18. TheIn conclusion, the present report describes a case of duodenal epithelioid angiosarcoma. Duodenal angiosarcomas may cause anemia and gastrointestinal bleeding. Because angiosarcomas sometimes show epithelioid cytomorphology, immunohistochemical analysis is useful for confirming the diagnosis.


Epididymal leiomyosarcoma (LMS) is a rare malignancy. Because the risk of recurrence is high, proper approach is important. Here, we present a patient with scrotal swelling who underwent surgical excision via scrotal incision, and the histopathological diagnosis was epididymal LMS. The decision was then made to perform inguinal radical orchiectomy. Epididymal leiomyosarcoma is a rare but important differential diagnosis of a scrotal mass. Radical orchiectomy with high ligation of the spermatic cord is the preferred approach. Considering the risk of loco‐regional recurrence, further studies to establish a standard adjuvant approach are needed. The patient had noticed the swelling about 6 months earlier. There was no medical history other than type 2 diabetes controlled by oral medication. At physical examination, a round, firm mobile scrotal mass measuring about 5 × 5 cm was detected. No lymph node enlargement was detected, and the left testis and scrotum were normal. Ultrasound examination of the scrotum was performed which revealed a rather well‐defined lobulated, hypoechoic mass lesion. Tumor markers beta‐human chorionic gonadotropin (BHCG), lactate dehydrogenase (LDH), and alpha‐fetoprotein (AFP) were normal. Whole body CT‐scan  showed no signs of metastasis.The patient underwent a scrotal surgery under general anesthesia. Intraoperative findings consisted of a para testicular firm round lobulated mass with elastic consistency measuring 5.5 × 4 cm with no adhesion to the testicle itself Figure . The masAccording to the histological diagnosis, reoperation was performed in 2 weeks (upon receipt of pathology report), in which inguinal radical orchiectomy and high ligation of the spermatic cord was accomplished. Testicular tissue was normal on histopathological investigation, with no tumoral involvement and vas deferens margin free of malignancy Figure , right.Further options, including adjuvant radiotherapy to reduce the loco‐regional recurrence risk, and close follow‐up for early detection of recurrence, were discussed with the patient. Nevertheless, the patient did not accept any further intervention. Although no adjuvant treatment was performed, the patient has been disease free during the last 10 months, and there is currently no clinical or para clinical evidence of recurrence.3Para testicular region contains different elements histologically, including epithelial, mesothelial, and mesenchymal tissues, which give rise to a few rare but histologically diverse tumors,Determining the interrelation between the para testicular mass and the testicle, and differentiation between benign and malignant masses using is difficult, both in clinical examination  and radiologic features (ultrasound imaging). Histologic examination of a surgically resected specimen and morphological and immunohistochemical evaluation is needed for definitive diagnosis. In the present case, the first surgery was undertaken via a scrotal approach, assuming the presence of a benign tumor which led to the histopathological diagnosis of a LMS with a close margin, resulting in the need for an oncologic surgery.Ünlu et al, reported and discussed the features and outcomes of seven cases of para testicular sarcoma in 2014, two of which were LMS. Both patients underwent radical orchiectomy with high cord ligation followed by adjuvant chemo‐radiation. One of the two faced mortality after lung metastasis and the other survived during the 18 months follow‐up, despite a loco‐regional recurrence.p = .024), which they described to be an independent risk factor for local recurrence. However, there was no significant difference in terms of DM and DSS between simple tumorectomy and high inguinal orchiectomy.No standard treatment protocol has been established because of the rarity of epididymal LMS. Current consensus is to perform radical orchiectomy with high ligation of the spermatic cord. If scrotal invasion is present, hemiscrotectomy is indicated.Considering the high risk of loco‐regional recurrence, adjuvant radiotherapy has been proposed as a useful option.Loco‐regional recurrence patterns which are reported in the literature include the following: scrotal,The experiences above, and other documents and literature, strongly support the role of long term follow‐up for all the patients, and the need for further investigations about the role of adjuvant radiotherapy.4Soft tissue sarcoma of the epididymis must be suspected in any para testicular swelling. Because the differentiation between benign and malignant masses using is difficult, both in clinical examination and radiologic features, if there is no loco‐regional invasion or metastatic disease and the plan is surgical excision, inguinal approach is a more reasonable and safe way. After histopathological diagnosis of LMS, recommendation of adjuvant therapy and long term follow‐up is mandatory. There is a need for further investigation about the role of adjuvant treatment, considering the loco‐regional recurrence risk.The authors declare that there is no conflict of interest to be reported.M.D. involved in study concept and design. M.D. and A.K. involved in acquisition of data. M.A. involved in histopathological review and preparation of article images. M.A. and M.D. involved in drafting of the manuscript.Informed consent was obtained from the patient to report their case, and the manuscript was approved at the Ethics Committee of Neyshabur University of Medical Sciences.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


The study describes an unusual case that a patient with previous history of adenocarcinoma of sigmoid colon who has developed chronic suppurative cholecystitis and peritonitis was misdiagnosed as metastasis. This case is presented to illustrate the importance of considering benign etiologies that may mimic metastatic disease when interpreting positron emmision tomography (PET)/CT scans. The CRP level was elevated,10.75 mg/L . Tumor marker carcinoembryonic antigen(CEA) was normal,whereas carbohydrate antigen 199 (CA19-9) level was elevated with a number of 121.2 U ml−1 .A 75-year-old male with previous history of adenocarcinoma of sigmoid colon (pT3N1aM0) who had undergone a colectomy and a followed 6 cycles of chemotherapy  presented with gallbladder and peritoneum masses 9 months after the surgery. Patient denied any abdominal pain or fever. The laboratory data including white blood cell and neutrophil cell count remained normal  + Adhersiolysis and Peritoneal Nodules Resection under laparoscope were performed.8 weeks after the cholecystectomy, the serum CA19-9 concentration has reached normal value. There are no current obvious indicators of colon cancer recurrence in this patient.Patient consent statement has been obtained and signed for this case report to be published.1,2 It has been reported in the literature that patients who has had sigmoid colon cancer and chemotherapy can develop acute episodes of chronic cholecystitis due to their impaired immunity.3 Chronic cholecystitis often manifests as even thickened of the gallbladder wall with homogeneous enhancement feature, and significantly high FDG uptake.4,5 The molecular basis of 18F-FDG uptake by inflammatory tissue is similar to that of tumor tissue, which is monocytes/macrophages in white blood cells (WBCs) take up 18F-FDG.6 In addition, the special type of chronic cholecystitis, xanthogranulomatous cholecystitis, is an uncommon inflammatory disease of the gallbladder and is characterized by marked proliferative fibrosis, macrophage infiltration, and foam cells invading gallbladder wall and it is difficult to distinguish from gallbladder tumors.7,8 This patient had some features similar to xanthogranulomatous cholecystitis, such as uneven thickening of the gallbladder wall with progressive enhancement, invading the liver and right colic flexure. In this case, foam cells can be seen in pathological examination, but no granulomas have formed. Therefore, a diagnosis of chronic suppurative cholecystitis with peritonitis was made. Reviewing diagnosis and treatment process and imaging examination, the reasons for the misdiagnosis are summarized as follows: (1) the lesions significantly took up FDG and invaded the liver and peritoneum. The morphological and metabolic characteristics on PET/CT were similar to those of malignant tumors. Previous studies9,10 have also shown that such inflammatory lesions with significant intense FDG uptake are easily misdiagnosed as malignant tumors. (2) Despite a history of chemo-induced immunology damage, there were no clinical signs and symptoms of acute episodes of chronic cholecystitis and peritonitis. (3) With a colon tumor stage pT3N1aM0 and an elevated serum CA19-9, it was easy to infer a serosa-penetration of sigmoid colon cancer and the metastasis to the gallbladder fossa, adjacent liver tissue and peritoneum, which was misdiagnosed as gallbladder tumor. (4) Conventional CT and enhanced scans both suggested a metastatic tumor, which subjectively affect the diagnosis of PET/CT examination. In actual work, atypical or rare cases may lead to misjudgment or misdiagnosis. It is worth noting that CA19-9 can also be elevated during cholecystitis, and attention should be paid to the characteristics of such cases in history, clinical manifestations and various examinations which may lead to important clues for diagnosis in the future.Chronic cholecystitis is the result of repeated episodes of acute cholecystitis or long-term stimulus from gallbladder stones, and also can be caused by decreased autoimmunity.The case presented illustrates patients sigmoid colon cancer can cause chronic cholecystitis due to impaired immunity.It is worth noting that CA19-9 can also be elevated during cholecystitis, not only in patients with malignant tumor.18F-FDG PET/CT scan during sigmoid colon cancer surveillance.Asymptomatic chronic suppurative cholecystitis and peritonitis mimicking metastasis by


Retroperitoneal liposarcomas are rare tumors arising from the soft tissue of the retroperitoneum and are of mesenchymal cell origin. They can reach a large size prior to causing symptoms and generally have a poor prognosis. We present the case of a 93-year-old lady presenting with a large retroperitoneal liposarcoma at the site of a previous colonic anastomosis for the adenocarcinoma treatment. It caused minimal symptoms initially, but surgical resection was undertaken when the tumor was found to be growing significantly in size. However, due to the tumor’s location and its invasion into surrounding structures, the resection was not feasible and subsequently abandoned. A retroperitoneal liposarcoma arising from the site of a previous colonic resection has not been previously described. A review of the diagnosis and current management of these lesions is also given. There are no established causative factors but risk factors include ionizing radiation, chemotherapy and some genetic conditions. Trauma, although suspected is not a known risk factor.We hereby present a case of an RPL occurring at the anastomosis site of a previous left hemicolectomy in a nonagenarian, which has not previously been reported on.An 88-year-old female underwent a left hemicolectomy for the resection of colonic adenocarcinoma. The histology of the left hemicolectomy showed moderately differentiated colonic adenocarcinoma, with 2 of 6 lymph node involvement i.e. T3N1. She did not receive any adjuvant therapy. Her recovery was uncomplicated, and she was eventually discharged to her general practitioner for ongoing annual surveillance. She had a follow-up colonoscopy, which did not demonstrate any recurrence.Five years later, at the age of 93, she presented to our service for investigation of a new mass in the left upper quadrant detected on a surveillance abdominal CT. She had only mild non-specific upper abdominal discomfort, and no bowel changes were noted. She also had a history of atrial fibrillation, for which she was on apixaban. No abdominal mass was palpable, and the examination was otherwise unremarkable. The CEA level had been stable and consistently less than 1ug/L . On the abdominal CT, a 4.7 x 3.0cm soft-tissue density mass was evident anterior to the left kidney, adjacent to the tail of the pancreas and the previous colonic anastomosis. AA core biopsy of the lesion was performed and showed an atypical spindle cell lesion, thought initially to represent a desmoid or low-grade sarcomatous lesion. It was unable to be characterized further. Given the lack of clinical symptoms, the small size of the lesion, and her advanced age, a decision was made for observation only with interval imaging. Throughout the observation period, the patient remained functionally very well.However, over a 12-month period, the lesion showed progressive enlargement, up to 12.7 x 8.6cm 1C.MDM2 on immunohistochemistry , RPLs generally appear as an encapsulated mass, that contains variable amounts of fatty and soft tissue. CT is most useful in delineating the relationship of adjacent structures, assessing local invasion, and checking for the presence of metastatic disease.In addition, MRI may demonstrate characteristics of the mass to distinguish between benign and malignant soft-tissue masses. Factors associated with malignant lesions are larger tumor size (> 10cm), thick septa (> 2mm), and less fat content (less than 75%).,Percutaneous biopsy is controversial as historically, there has been a fear of tumor seeding of the biopsy tract. However, a biopsy is required in cases of diagnostic uncertainty or if neoadjuvant treatment is to be considered. A core biopsy has been shown to be both accurate and safe.There are five histologic subtypes of liposarcomas: (i) well-differentiated, (ii) dedifferentiated, (iii) myxoid, (iv) pleomorphic, and (v) liposarcoma, not otherwise specified. More than 93% of all RPLs are of the well-differentiated and dedifferentiated subtypes.murine double minute 2 (MDM2) and CDK4 genes. MDM2 encodes a protein that is responsible for the degradation of p53, a known tumor suppressor gene, and CDK4 encodes an oncoprotein that promotes G1/S progression of the cell cycle. Both of these genes are characteristically amplified in well-differentiated and dedifferentiated RPLs.Recent advancement in molecular genetics has also shed some light on the genes implicated in liposarcomas. Among these is the The treatment of choice for non-metastasized retroperitoneal soft tissue sarcoma is complete surgical excision with negative margins. Complete en bloc excision may require adjacent organ and fat resection, but even then, surgical margins are often narrow.Preoperative, intraoperative, and postoperative radiotherapy (RT) have all been used to treat RPS, but their role and effectiveness continue to be debated. Preoperative RT tends to be used as the lesion may be accurately targeted and help reduce toxicity to nearby organs, including bowel that may be displaced by the tumor. Furthermore, an unresectable tumor can be converted to a potentially resectable one with the use of RT.STRASS was a randomized multicenter international trialSystemic treatments for patients with RPL have mainly occurred in the setting of clinical trials and are typically reserved for those with high-grade tumors. This has been used in both neoadjuvant and adjuvant settings, and doxorubicin, ifosfamide, and anthracycline-based chemotherapy regimens have been used. However, data is limited to small studies, and results have been disparate.MDM2 and CDK4, the two most commonly amplified oncogenes, showed some early promising results.,A better understanding of molecular genetics has also led to promising targeted therapy for RPLs. Among others, inhibitors of In the present case, the RPL developed adjacent to the previous colonic anastomosis in the left upper quadrant and was found to be inseparable from the colon and adjacent organs intraoperatively. It is difficult to determine whether the sarcoma developed as a result of the previous surgery or as a primary entity, but its proximity to the previous resection site makes the former far more likely. At the time of the left hemicolectomy, there would have been the dissection of the left colonic and transverse mesentery with a breach into the retroperitoneal region. This may have triggered an abnormal regeneration process to occur, leading to the development of the RPL.In our patient, stable tumor markers and a recent normal colonoscopy was reassuring and ruled against local recurrence. A diagnosis of a sarcomatous lesion was made after a sample was obtained from a core biopsy of the lesion. Watchful waiting with surveillance scanning was taken initially as the patient was asymptomatic and would be the initial preferred approach in a nonagenerian. However, with the increasing size of the lesion and increase in discomfort, an observational approach was no longer appropriate. The decision to proceed to operative intervention was challenging but after extensive discussion, the patient was agreeable to this, despite her advanced age. At operation, the extent of the RPL was certainly underappreciated on imaging, which was then confirmed to be unresectable due to local invasion.Decisions such as these in elderly patients are indeed challenging and clearly the risks and benefits of a major operation need to be carefully balanced and explained to the patient. Careful review of the imaging may demonstrate signs of local invasion which may alter the approach and decision making in these complex clinical situations.To our knowledge, this is the first reported case in which an RPL developed following previous intra-abdominal surgery. RPL may mimic local recurrence of previous malignancy in this setting. Although rare, liposarcoma, and other soft tissue sarcomas, should be kept in mind when investigating potential lesions in the retroperitoneum, particularly in previous surgery settings. Tissue sampling is often required to make the diagnosis. Further studies are needed to consolidate the link between retroperitoneal liposarcoma and previous intra-abdominal surgery. Treatment of RPL is multimodal and should ideally take place in a multidisciplinary center specializing in sarcoma treatment. Complete surgical excision is however, the mainstay of treatment.


Phosphaturic mesenchymal tumor (PMT) is a rare neoplasm causing oncogenic osteomalacia. Surgery remains the definitive treatment for PMT, and radiotherapy is seldom employed. However, surgery for PMT involving the head and neck is often difficult due to the local invasion and complicated anatomy. We report the first case of PMT, which was successfully treated with the combination of radiotherapy and supplementation of activated vitamin D.A 55-year-old woman suffered from pain in the hip and bilateral femur. Serum phosphate and calcium decreased to abnormal levels. Serum alkaline phosphatase and fibroblast growth factor 23 increased to abnormal levels. The hearing loss of the right ear had continued and a middle ear tumor was revealed.Subsequent biopsy provided the diagnosis of PMT that caused oncogenic osteomalacia. These clinical and pathological characteristics were consistent with and provided the final diagnosis of benign PMT.Surgery of the PMT was difficult and the patient underwent radiotherapy. The prescribed dose was 36 Gy in 10 fractions. Simultaneously, the patient started supplementation of 1,25-dihydroxyvitamin D3 (1–2 μg/day) and continued for 2 years.Near-complete resolution of the symptoms was achieved and abnormal laboratory values recovered. At 5 years of follow-up, the irradiated tumor showed no regrowth. Severe hearing loss of the right ear was not observed.Radiotherapy was effective for the PMT and could be an important treatment option for inoperable cases. So far, there have been no reports of successful treatment of PMT with radiotherapy. We herein report a patient presenting with oncogenic osteomalacia due to a PMT in the middle ear, who was successfully treated with the combination of radiotherapy and supplementation of activated vitamin D.Phosphaturic mesenchymal tumor (PMT) is a rare neoplasm causing oncogenic osteomalacia characterized by increased renal phosphate excretion and hypophosphatemia.2A 55-year-old woman visited an orthopedic surgery department with a complaint of pain in the hip and bilateral femurs. There was no history of trauma, and abnormal findings on plain radiography were not identified except for a mild radiolucent shadow in the left femur Fig. A. In add3) was the visible lesion on MRI. Taking the direction of tumor invasion into consideration, the clinical target volume (10.8 cm3) was adjusted based on anatomical structures. The planning target volume (20.9 cm3) was defined with a 3-mm margin around the clinical target volume. Subsequent planning and treatments were carried out with the Tomotherapy version 5.0.1 treatment planning station and TomoTherapy HDA system . The TomoHelical mode was employed. The prescribed dose was 36 Gy in 10 fractions over 2 weeks once a day to cover 50% of the planning target volume. The field width, pitch, normal modulation factor, and irradiation time was 1.0 cm, 0.43, 2.0, and 5.6 minutes, respectively. Our method of helical tomotherapy was previously described in detail. The constraints for normal organs were equal to the tolerance dose of normal tissue in radiotherapy.Figure The patient underwent radiotherapy because surgery was difficult due to the local invasion. The gross tumor volume 3.8 cm.8 cm3 waAfter radiotherapy, the patient was followed every 2 months during the first year, and at intervals of 6 or 12 months thereafter. Regular follow-up included pure-tone audiometry, blood tests, and MRI. At 2 months of follow-up, serum calcium recovered dramatically owing to the supplementation of 1,25-dihydroxyvitamin D3. At 8 months, normalization of serum phosphate and alkaline phosphatase levels was achieved and maintained thereafter. Figure 3 PMT is a rare neoplasm arising in bone and soft tissue that inappropriately produces FGF23, which has phosphaturic activity inhibiting renal tubular reabsorption of phosphate and renal conversion of 25-hydroxyvitamin D3 to 1,25-dihydroxyvitamin D3 (active form of vitamin D). This results in hypophosphatemia and ultimately bone loss. PMT is considered the most common cause of oncogenic osteomalacia. PMTs arising in the head and neck are extremely rare, mostly in the extremities and appendicular skeleton.,3 PMT is usually benign but the local invasiveness is a characteristic feature.Oncogenic osteomalacia is known as a rare and curable cause of osteomalacia characterized by increased renal phosphate excretion and hypophosphatemia.,8 and radiotherapy is seldom employed. However, surgery for PMT involving the head and neck is often difficult due to the local invasion and complicated anatomy, as the present case exhibited. Radiotherapy should be considered as an alternative treatment for inoperable cases. Cases of PMTs treated with radiotherapy were summarized in Table –12 It was reported postoperative radiotherapy for benign PMT was effective to improve oncogenic osteomalacia. Although the detailed mechanism of the effectiveness of radiotherapy for benign PMT was still unclear, the obstruction and fibrosis of the tumor vessels could occur thus inhibiting the growth, similar to those observed in other hormone- or cytokine-producing tumors.,14 Considering the mechanism, radiotherapy could take some time to resolve the symptoms compared with surgery. Although PMTs and acoustic tumors were different types of tumors, the tumor location and surrounding normal tissues of the present case were similar to acoustic tumors. Considering the PMT was benign tumor, the employed dose was decided based on the excellent local control rates of acoustic tumors.,16 We considered the dose was probably enough to control benign PMT. It was considered that the employed dose was appropriate to prevent severe toxicities of normal organs around the target. Various studies on fractionated stereotactic radiotherapy for acoustic tumors have been reported in literature.,18 Especially in hearing outcomes, it was reported that the mean cochlear dose <40 Gy was a significant factor associated with hearing preservation. Indeed, severe hearing loss was not observed in the present case. Malignant transformation from benign PMT was reported in the long-time follow-up. Therefore, we will carefully continue the follow-up of the patient.The definitive treatment for oncogenic osteomalacia is surgical resection of the causative PMT,4This was the first case report showing successful treatment of benign PMT with the combination of radiotherapy and supplementation of activated vitamin D. This report would serve to increase the awareness of this uncommon disease and could be a reference for employing radiotherapy in future inoperable cases.We would like to thank all staffs at Narita Memorial Hospital and our hospitals.TT contributed to collect data and draft the manuscript. NT contributed to collect data and revise the manuscript. YS contributed to the treatment of oncogenic osteomalacia. SB contributed to the pathological diagnosis of phosphaturic mesenchymal tumor. MF contributed to the staining of histopathology specimens. CS contributed to generate the radiotherapy planning. YS contributed to translate and revise the manuscript. All authors read and approved the final manuscript.Data curation: Taiki Takaoka, Natsuo Tomita, Yoji Shido, Satoshi Baba, Mayu Fukushima, Chikao Sugie.Investigation: Yoji Shido, Satoshi Baba, Mayu Fukushima, Chikao Sugie.Writing – original draft: Taiki Takaoka.Writing – review & editing: Natsuo Tomita, Yuta Shibamoto.


In 2016, the World Health Organisation Classification (WHO) of Tumours was updated with diffuse leptomeningeal glioneuronal tumour (DLGNT) as a provisional unit of mixed neuronal and glial tumours. Here, we report a DLGNT that has been re-diagnosed with the updated WHO classification, with clinical features, imaging, and histopathological findings and a 9-year follow-up. A 16-year-old girl presented with headache, vomiting, and vertigo. Magnetic resonance imaging (MRI) demonstrated a hyperintense mass with heterogenous enhancement in the right cerebellopontine angle and internal auditory canal. No leptomeningeal involvement was seen. The histological examination revealed neoplastic tissue of moderate cellularity formed mostly by oligodendrocyte-like cells. Follow-up MRI scans demonstrated cystic lesions in the subarachnoid spaces in the brain with vivid leptomeningeal enhancement. Later spread of the tumour was found in the spinal canal. On demand biopsy samples were re-examined, and pathological diagnosis was identified as DLGNT. In contrast to most reported DLGNTs, the tumour described in this manuscript did not present with diffuse leptomeningeal spread, but later presented with leptomeningeal involvement in the brain and spinal cord. Our case expands the spectrum of radiological features, provides a long-term clinical and radiological follow-up, and highlights the major role of molecular genetic testing in unusual cases. In 2016, the World Health Organisation (WHO) Classification of Tumours of the Central Nervous System (CNS) was updated with the inclusion of diffuse leptomeningeal glioneuronal tumours (DLGNTs) as a provisional unit of mixed neuronal and glial tumours, after an increasing number of cases reported on tumours observed seeming both neurocytoma-like and containing variable glial components, leading to a conclusion of a new type of neuronal–glial tumours ,4. Due tMolecular genetic studies often pose a combination of KIAA1549 and the serine/threonine protein kinase B-raf (BRAF) gene (KIAA1549-BRAF fusion), as well as the short arm of chromosome 1 (1p) and/or the long arm (19q) of chromosome 19 deletions . The mosHere, we report a case of DLGNT that has been re-diagnosed with the updated WHO classification, with clinical features, imaging, and histopathological findings, as well as a 9-year follow-up period, including literature research. Seeking to raise awareness of this novel entity, we also hope to ease rapid diagnosis in affected patients, and provide knowledge on the biological behaviour of this neoplasm over time.In July 2011, a 16-year-old girl was admitted to Hospital of Lithuanian University of Health Sciences Kauno klinikos due to severe headache, vomiting, and vertigo lasting 2 days. She had a half-year history of similar paroxysms usually beginning with numbness in hands or in one side of face or leg. Neurological examination revealed right-sided peripheral facial paresis, horizontal nystagmus, painful exit points of branches of the right trigeminal nerve, slight deviation of the uvula to the right, right-sided hemiparesis, and cerebellar ataxia. Moreover, papilledema was observed. Brainstem evoked potentials response audiometry showed no clear waves on the right side although hearing was normal. Magnetic resonance imaging (MRI) of the head demonstrated a hyperintense mass on T2W/FLAIR images with heterogenous enhancement in the right cerebellopontine angle cistern and internal auditory canal . All figDuring surgery, the tumour was found growing from the brainstem, inferoanterior margin of foramen Luschka, invading the proximal part of the right facial nerve, surrounding the right cranial nerve VIII, also extending to right cranial nerves V, IX, and X. The tumour was removed along with resection of the invaded part of the facial nerve. The histopathological examination revealed neoplastic tissue of moderate cellularity formed mostly by oligodendrocyte-like cells in sparse myxoid stroma. After surgery, total right-sided facial palsy developed as well as hearing having deteriorated in the right ear. A few months later, reconstructive surgery of the facial nerve was performed by creating hypoglossal-facial nerve anastomosis with sural nerve interposition graft. Five months after the first MRI, another MRI was performed, and it showed a new small enhancing nodule in the prepontine cistern at the pontomedullary junction, in the expected location of the left abducens nerve .After 4 months when symptoms of raised intracranial pressure recurred, additional findings were detected on follow-up MRI. Most of the subarachnoid cisterns, Sylvian fissures, sulci of superior parts of the cerebellum, and the lower part of the fourth ventricle were filled with diffuse non-contrast-enhancing multiple small cyst-like lesions . These lThe girl underwent induction chemotherapy according to low-grade glioma protocol ; however, it was not effective and local radiotherapy was administered. Due to tumour-induced disorders of CSF reabsorption and further progressive hydrocephalus, a ventriculoperitoneal shunting was performed. Despite this measure, the patient’s status worsened as cerebellar ataxia, weakness of lower limbs, bulbar symptoms started to increase.Later the girl was treated in Klaipeda University Hospital. In May 2013, a follow-up MRI demonstrated enlarged cystic lesions in the subarachnoid spaces with compression of the brainstem and the cerebellum and vivid leptomeningeal enhancement extending to the spinal canal . T2W/FLAIn 2017, follow-up brain MRI scans showed decreased leptomeningeal enhancement and slight decrease in size of cystic lesions in the brain; although, atrophy of the brainstem and cerebellum had progressed. However, spread of the tumour was found in the spinal canal through all its length manifested by diffuse meningeal enhancement and multiple cystic intra- and extradural lesions causing compression of the spinal cord. The girl received radiotherapy to the whole spinal cord; however, masses in the spinal canal progressed . In 2018Due to impaired vision, further loss of hearing, and ability to walk, an MRI of the brain and spine was repeated in 2020. MR brain revealed residual changes—cystic leptomeningeal-subpial nodular lesions that were hypointense on T2W/FLAIR, and did not show contrast enhancement in the posterior fossa and along the basal cisterns, surrounding the brainstem, cranial nerves, and cerebellum. Imaging of spinal cord revealed cystic nodular lesions resembling those found in the brain and causing persistent, multisegmental spinal cord compression . On demand biopsy samples removed from the tissues of the brain surface in 2012 and 2013 and the Sylvian fissure leptomeninges were re-examined. The pathological examination disclosed a tumour composed of comparatively monomorphic oligodendrocyte-like cells with moderately sized round nuclei and nucleoli and perinuclear halos. The tumour cells formed large accumulations in the leptomeninges with hyalinized small blood vessels around them. There were neither neurocytic rosettes or foci of necrosis, nor microvascular proliferation. No significant mitoses were observed. The Ki67 proliferation index proved to be low (2%). Immunohistochemistry showed that the tumour cells were highly reactive to S100, less reactive to glial fibrillary acidic protein (GFAP) and synaptophysin, and negative for epithelial membrane antigen (EMA) reactivity. IDH1 and IDH2 mutations proved to be negative. Fluorescence in situ hybridisation (FISH) examination showed a deletion of 1p36. The BRAF V600E expression (VE1 antibody) was not detected. Based on these findings, the pathological diagnosis was identified as DLGNT (of an unspecified grade) . In the updated 2016 edition of WHO Classification of Tumours of the CNS, DLGNTs have been classified as a separate entity . DLGNTs Although we had a DLGNT occurrence in a 17-year-old female patient in our case, research of the literature on published cases of DLGNTs shows that the median age of onset of a DLGNT approximates 4 years, with a male prevalence in 58 out of 91 cases (64%) ,13,14. AHistologically, this lesion has the classic oligodendroglial pattern: round cells with surrounding halos . AstrocyAs in our case, leptomeningeal cystic changes may be absent in the early phase of the disease, thus further hampering the diagnosis. As the disease progressed, the DLGNT in our case presented with a classical imaging appearance. The most common MRI finding of DLGNTs that could serve as an important diagnostic marker of this disease is leptomeningeal growth involving the spinal cord and basilar cisterns, frequently accompanied by cystic T2W-hyperintense lesions alongside the basilar cisterns and subarachnoid space, often in the absence of a solid intraparenchymal brain tumour ,24. WhatOne of the main features of DLGNTs is diffuse leptomeningeal growth, for which the differential diagnosis is extensive. The primary radiological diagnosis in our case was difficult because diffuse multicystic lesions in the brain did not show contrast enhancement. On the other hand, the most common cause of diffuse leptomeningeal enhancement is meningitis, with a variety of aetiologies. Of all the causes, bacterial and viral meningitis with thin linear meningeal enhancement is the most prevalent . FollowiDLGNTs are usually characterised by periods of stable disease and a slow course, with most patients surviving for decades, except for the cases of secondary hydrocephalus, which has a high morbidity rate ,34,35. HDespite the breakthrough in our knowledge of the diagnostic substantiation and clinical appearance of DLGNTs, there is still no consensus on the suitable perspective to treatment for these patients and reports on the treatment modalities being used vary widely. Chemotherapy with carboplatin and vincristine or temozolomide has been suggested as the first-line approach for this condition, with radiotherapy as a resort to the cases when the disease progresses ,36. DespIn the light of the recent WHO classification amendment and the rarity of this entity, many radiologists and referring medical practitioners may not yet be aware of DLGNT. It commonly presents with diffuse abnormal leptomeningeal growth, but radiological findings may vary. Thus, substantiation of the diagnosis by molecular genetic means is an ideal approach. Our patient’s case expands the spectrum of radiological findings, and gives an opportunity for a long-term clinical and radiological follow-up, which contributes to our understanding of the conduct of DLGNTs, and highlights the major role of molecular genetic testing in unusual cases.


Cholocystocolonic fistulas (CCFs) represent a rare medical entity. Previous inflammatory processes in the abdomen, especially in the gallbladder and surgeries are all related to their appearance. There are not typical findings concerning the clinical image and the therapeutic approach varies between patients. Herein, we present a case of a 46-year-old patient, with a history of perforated duodenal ulcer, suffering from abdominal pain and diarrheas. A computed tomography (CT) demonstrated air inside the biliary system. A laparotomy was conducted to the patient and no complications had occurred. In addition, a review of literature regarding the clinical presentation and the therapeutic options for this disease are discussed in this manuscript in relation to our patient. The cholocystocolonic fistulas (CCF) consist a rare entity which occurs approximately to 1 to 10.000 cholocystectomies and appears mostly in females during the seventh decade of life ,3. The cA 46-year-old female patient referred to the emergency department with a 14-day history of abdominal pain in the upper abdomen, including the right upper quadrant and epigastrium. In addition, diarrhea and weight loss were reported from the subject. Her medical history included a perforated duodenal ulcer 3 years earlier, for which she underwent a Billroth's II operation. Postoperatively, she was fit and healthy.Clinical examination revealed hyperactive bowel sounds during auscultation. Furthermore, tenderness was noticed to both deep and superficial palpation in the epigastrium and right upper quadrant of the abdomen. The rectum was empty when digital rectal examination was performed.3 was demonstrated. The aerial blood gases (ABGs) showed mild metabolic acidosis.Laboratory findings demonstrated elevated levels of C-reactive protein (CRP): 22mg/L, aspartate aminotransferase (AST): 55IU/L, alanine aminotransferase (ALT): 74IU/L and alkaline phosphatase (ALP): 170mg/L. A left shifted blood cell count with 13.540/mmThe abdominal radiograph did not show any significant abnormality such as pneumobilia or dilated bowels. In the computed tomography (CT), there was no free intrabdominal gas or fluid and a new perforation of an abdominal organ was excluded. The gallbladder was thick, with enhanced wall after contrast administration and contained air inside, which raised the suspicion of a CCF even though no apparent fistulous communication was shown . Initialet al. reported that diarrhea appears in 71% of patients [The pathogenesis of the CCF varies. Except for the gall bladder disease and the acute cholecystitis, other conditions correlated with this lesion are previous cholocystectomy, gastric surgery and iatrogenic or traumatic abdominal lesions . In our patients . The upppatients . Our casThe complications of this entity can affect many different systems. Malabsorption leading to osteomalacia, heart failure and megaloblastic anemia, caused by diarrheas are another manifestation of this disease . The moset al. reported that CT-intravenous cholangiography was used for the diagnosis of this disease [et al. diagnosed a CCF through gadoxetic-acid magnetic resonance cholangiography [et al. managed to diagnose preoperatively a CCF through endoscopic ultrasound [Pneumobilia is the pathognomic radiological sign for the diagnosis of CCF in both abdominal X-ray and CT, even though it is not a frequent finding . In the  disease . Mourri iography . Abdominiography . Okada etrasound . Except trasound . Preopertrasound . Althougtrasound . Due to trasound ,14.et al. conducted a therapeutic sphincterotomy [et al. performed laparoscopic surgeries of CCF and reported a 4.8% and 11.1% rate of major and minor complications respectively [Therapeutic approaches vary nowadays concerning the treatment of CCF. In non-complicated cases less invasive and aggressive methods are applied in order to minimize the surgical risk. Goldberg terotomy . The sucterotomy . Chowbeyectively . In addiectively .Concerning the treatment of the complicated forms, this varies depending on the complication. Enterolithotomy or surgical resection can be conducted on gallstone ileus . It is wThe cholocystocolonic fistulas consists a rare disease which should be suspected in many different cases of abdominal pathology, even if its most frequent symptoms, signs and radiological findings are missing. Its preoperative diagnose requires high clinical suspicion and collaboration between different specialties. This is required in order to improve prognosis since its randomly intraoperative discovery is a very demanding surgical challenge with possible dangerous complications for the patient.


Ovarian mucinous cystic tumors may be associated with various types of mural nodules, which can be classified as benign or malignant . However, anaplastic malignant nodules have rarely been reported. Here, we present a case of a 35-year-old woman who presented with abdominal discomfort. Ultrasonography showed a large cystic mass in the pelvic and abdominal cavities measuring 337 × 242 mm. Abdominal computed tomography revealed upper anterior and posterior uterine pelvic cystic lesions based on multiple nodule partition walls and classes. During hospitalization, the patient underwent exploratory laparotomy, which revealed a poorly differentiated ovarian malignant tumor, and subsequent surgical excision was performed. The pathological analysis of the surgical samples of the right ovary revealed a mucinous ovarian tumor, while the mural nodules were classified as anaplastic carcinoma. After surgery, the patient started receiving chemotherapy. Unfortunately, the patient died 6 months later. Mucinous tumor occurring with an anaplastic carcinoma is rare, and the current diagnostic methods are not sufficient in providing an early and accurate diagnosis. Most patients are already in the advanced stage upon diagnosis and combined with poorly differentiated pathological features, the prognosis is extremely poor. Clinicians need to improve the clinical evaluation before surgery and conduct preoperative preparation and communication to improve the prognosis of patients as much as possible. B-Ultrasonography (B-US) showed a huge mixed mass in the pelvic cavity measuring 337 × 242 mm. The mass had clearly defined boundaries, with most of the liquid-filled dark areas separated by strong light bands. Color Doppler flow imaging revealed a blood flow signal above the divider. The diagnosis based on the B-US was ovarian cystadenoma. Abdominal computed tomography results are as follows: a huge cystic space-occupying lesion can be seen in the anterior and upper part of the pelvic uterus. The lesions on the scan level are not complete. The scan range is about 284 × 205 mm on the larger level, the upper and lower diameter is about 151 mm (incomplete). The lesion shows multilocular cystic changes, the cyst wall is thin, multiple partitions can be seen, and several mural nodules can be seen, and the larger mural node is 28 × 23 mm, slight enhancement was seen on the enhanced scan. It seems that the blood supply artery came from the branch of the uterine and ovarian arteries. Large cystic space-occupying lesions with a size of about 89 mm were also seen behind the uterus. The wall is thin, and a sheet-like enhancement shadow can be seen at the left front. Bilateral ovaries showed unclearly. The anterior position of the uterus is obviously compressed, and the anterior and posterior cystic space-occupying parts seem not to be connected. The focus behind the uterus seems to be closely related to the left ovary. A large amount of effusion shadow can be seen in the pelvic cavity. Large lymph nodes with a size of about 17 mm can be seen next to the iliac vessels on the right side of the pelvic cavity × 12mm, enhanced scanning was more obvious. No abnormality is found in the pelvic bone structure . ExploraDespite being highly malignant ovarian tumors, there is a lack of effective diagnostic tools and molecular markers to confirm the diagnosis of mucinous ovarian tumors. Mucinous tumors usually occur in young women , and in Ovarian mucinous tumors represent a group of rare neoplasms with a still undefined cell of origin but with an apparent progression from benign to borderline to carcinoma . OvarianThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.This report was approved by the Affiliated Hospital of Guangdong Medical University. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.AF and HH performed the operation. XZ, ZM, and YC were involved in the acquisition of data and preparing the figures. XZ, HH, QZ, ZM, YC, WW, and AF wrote the manuscript. QZ revised 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


One of the rare but serious causes of acute abdomen is gastric volvulus. It is considered an emergent surgical condition when it takes place acutely due to the risk of gastric strangulation, gangrene, and perforation. In this study, we introduce a case of a previously healthy young adult patient who presented with sudden severe epigastric and left upper quadrant abdominal pain along with nausea and retching following insufficient mastication and rapid swallowing of large amounts of vegetables. Radiological studies with chest and abdominal X-rays were in favor of acute gastric outlet obstruction and finally, laparotomy confirmed the diagnosis of acute, primary mesenteroaxial gastric volvulus. We postulated a probable justifying mechanism of the presence of a flaccid gastrocolic ligament (found through the laparotomy) besides rapid entrance of great pieces of vegetables into the stomach precipitated instant gastric rotation. Gastric volvulus is an uncommon but potentially life-threatening clinical condition, defined as a pathological rotation of the stomach along its long  or short  axis leading to the gastric inlet and outlet obstruction at variable levels ,2. It isA 32-year-old man presented to the emergency department of the hospital with the complaint of severe acute abdominal pain. The patient felt completely healthy until the afternoon of the day before the presentation when he was eating two plates of uncooked vegetables such as parsley, basil, and coriander; that were ingested without enough mastication, and after about ten minutes, he developed sudden onset, severe abdominal pain located at the epigastric and left upper quadrant (LUQ) region. Then, about ten minutes later he noticed an abdominal distention feeling a mass at the LUQ area and acute dyspnea ensued. His abdominal pain was sharp in quality and he rated the intensity of the pain at 10 of 10 , but no radiation. It was partially alleviated by the knee-chest position and was exacerbated by the supine position. He also reported having nausea and retching but no emesis. The patient's medical history was mild dyspepsia from 20 years ago which was under treatment by Ranitidine consumed as needed and surgical history of appendectomy 4 years ago. There was no significant and relevant family, allergic, social, or habitual history. Upon physical examination; the patient was terrifically ill and was crying and urging for help desperately while he had a knee-chest position on the ground. In vital signs, he had a blood pressure of 110/85 mmHg, pulse rate of 96 beats per minute, a temperature of 36.5 centigrade, and respiratory rate of 28 breaths per minute. On abdominal examination, upon inspection, there was a local distention at the LUQ and epigastric region. The patient refused deep palpation and had a voluntary guarding abdomen but on light palpation, a severely tender mass was found at the LUQ. Other systemic examinations were unremarkable. In laboratory data, the white-cell count was 8400 per cubic millimeter, with 77.2 % neutrophils, 16.4 % lymphocytes. The hemoglobin level was 15 g per deciliter, and the platelet count was 169,000 per cubic millimeter. The serum level of sodium was 139 mmol per liter, potassium level 4.7 mmol per liter, Blood urea nitrogen level 23 mg per deciliter, creatinine level 1 mg per deciliter, and blood glucose 111 milligrams per deciliter. Venous blood gas analysis showed a pH of 7.33, partial pressure of carbon dioxide of 43.9 mm Hg, and a bicarbonate level of 23.1 mmol per liter. The liver function test, amylase, lipase, erythrocyte sedimentation rate, C-reactive protein, prothrombin time, partial thromboplastin time, and the international normalized ratio were within the normal range. Abdominal X-ray (supine and upright) showed a massively dilated stomach in an expected intraabdominal location with collapsed small bowel loops  and 2. APresented here was a case of a young adult patient who developed classic symptoms of acute gastric volvulus: severe sudden epigastric pain, intractable retching without vomiting, and inability to pass a nasogastric tube (Bouchard's triad) As mentioned in the case presentation, some gangrenous parts of the stomach were noted which led to partial gastrectomy; the fact that underscores the importance of early diagnosis of this surgical emergency. Gastric volvulus rarity and numerous causes of sudden abdominal pain result in a low clinical index of suspicion for this entity ,3, thereBased on the review of the literature, immediate surgical intervention comprising emergency laparotomy is recommended following diagnosis of acute gastric volvulus Recently, laparoscopy is gaining more attention in the treatment of gastric volvulus and some studies have demonstrated its satisfactory outcomes and lower downtime as an alternative; however, data comparing laparoscopy to open is still scant In sum, this report aims to increase physicians awareness about the various presentations of this rare disease and draw their attention to that when a patient presents with severe acute upper abdominal pain and fundamental imagings are in favor of acute gastric outlet obstruction, gastric volvulus can be an emergent diagnosis which requires immediate surgical consultation and intervention.


Posteriorly migrated disc extrusion may mimic tumoral masses on MRI with contrast; still, this diagnosis must be evoked in patients presenting acute low back pain with a posterior epidural mass.We describe a case of epidural posterior migration of an inflammatory lumbar disc herniation in a young patient with acute lumbosciatica. MRI showed an intracanalar mass with intense global enhancement, which is an uncommon feature of this rare condition. Migration of an excluded or non-excluded disc herniation usually occurs into the anterior epidural space. Posterior migration of excluded disc fragments is an extremely rare entity and is a radiological challenging diagnosis. The differential diagnosis includes neoplastic masses that may lead to unnecessary surgical excision in case of misdiagnosis -4.We report a case of dorsally sequestrated lumbar disc herniation that was initially diagnosed as a meningioma on MRI. We then analyze the clinical and imaging features in light of literature data.A 28-year-old man was admitted to the emergency department with chronic low back pain. He reported acute sciatica irradiating to the left lower limb for three days, exacerbated by movement, not resolving with usual analgesic treatments. He had no sensory-motor deficits and the physical examination was normal except for a left Lasègue sign. An MRI was prescribed followed by an appointment for a neurosurgical consultation within two weeks. The MRI revealed a minor discopathy and an intracanalar expansive mass, measuring 14 mm of major axis, located in the left posterolateral epidural space. It was displacing the dural sac and the left S1- S2 roots to the right. Because of this contact with the left lamina of S1 and the intense enhancement after contrast injection, the diagnosis made was meningioma Figures -1F. The patient lost to follow-up and no additional support was carried out until he was referred by his doctor for a recurrence of low back pain after a year. The control MRI no longer shows the previously described intracanal mass with intense enhancement in L5-S1 Figures -2F. We dAnatomically, migration of an excluded disc fragment usually occurs in the anterior epidural space and is sub-ligamentary. The posterior longitudinal ligament includes a medial septum which subdivides the anterior epidural space into a right and left space, thus providing an anatomical barrier to right-left disc migration. In addition, the lateral membranes that close this anterior epidural space and the spinal nerves represent two further barriers to anteroposterior migration ,2. ThereExcluded disc fragment might be considered in cases with a lumbar posterior epidural mass in a patient presenting with acute lumbago. MRI with gadolinium is the best diagnostic tool, with a classically peripheral enhancement of the disc fragment. However, in the case of severe inflammatory disc herniation, a complete enhancement of the disc fragment would constitute a pitfall and this diagnosis should not be excluded.


Pleuropulmonary blastoma (PPB) is a rare malignant intrathoracic mesenchymal tumour with a variable aggressiveness. It is the most common primary malignancy in the lung during childhood. In this study, we present a case of a 3-year-old male child who complained of persistent dry cough. Radiographs suggested the diagnosis of PPB, which was been confirmed by the histo-pathological examination of a biopsy taken from the tumour under CT guidance. This case was reported to emphasise the importance of radiology, whether diagnotic or interventional, in diagnosing rare cases such as PPB. Despite being rare, they are considered the most common primary cancers in the lung during childhood,2 especially in those who are under 5 years of age.3 The first two years of age remain the highest risk for developing PPB, with about 90% of the cases occuring within this age group.3 PPB is divided into type I, II & III according to histological type of the tumour. Each of the subtypes correlates to the age at diagnosis and the overall prognosis of the patient.4 The main aim of reporting this case is to highlight the importance of both diagnostic and interventional radiology in helping other physicians to reach rare diagnosis correctly.Pleuropulmonary blastoma (PPB) accounts for 0.25 to 0.5% of all primary lung neoplasms.3, an elevated C reactive protein (CRP) level of 108 mg/l, and anaemia with a haemoglobin level of 9.8 g dl−1.A 3-year-old male child presented to our emergency department with a history of persistent non-productive cough of 4 days duration. He had a history of hospitalisation once for acute bronchiolitis at the age of 1 year. His family history was unremarkable. Upon clinical evaluation, he had tachypnea, intercostal retractions, absent air entry on the right lung and abdominal distention. Otherwise, the clinical examination was normal. Laboratory investigations revealed leukocytosis up to 14,900 / mmA chest X-ray  was perf1 The pathogenesis of these tumours remains uncertain, but due to their resemblance to fetal lung tissue, pluripotent pulmonary blastomas have been postulated to be the origin of the disease. They occur mostly in the infants and young children, however, similiar cases had been reported in adults.5–7Lung malignant tumours during childhood are considered a rare entity, representing only 0.5–1% of primary lung cancers. Pulmonary blastomas are uncommon fast-growing lung neoplasms that account for approximately 0.25–0.5% of primary lung malignancies.8 They are also associated with dysplasia syndrome in 33% of the cases.9 The association of DICER1 mutations and PPB is reported in approximately 66% of the cases.2 Therefore, all patients with PPB should be screened for DICER1 mutation. If DICER1 mutation is detected during screening, the possibility for the patient to develop malignancies in other organs must be considered. In 30% of cases, patients with PPB may also present with multilocular cystic nephroma, and, very rarely, Wilms tumor.9 Following the initial description by Barrett and Barnard in 1945 , pulmonary blastomas were classified into three histological subtypes10 : I, II, and III. Type I is a purely cystic lesion (14%), type II tumours have both cystic and solid components (48%) and type III are purely solid (38%). The classification has also a prognostic value, type I being the least malignant and type III the most malignant lesion.Up to date, no definite causative agent has been determined, but some associations have been reported. PPBs are associated with type IV congenital pulmonary airway malformations.10,11 Symptoms, when present, may include fever, dyspnoea, respiratory distress, cough. Rarely, hemoptysis, chest pain, weight loss, anorexia, fatigue, or even neurologic symptoms can occur. Currently, there is no specific serum marker for pulmonary blastomas.10The clinical picture of blastomas is highly variable. There are no specific presenting signs or symptoms of biphasic pulmonary blastomas. Some studies suggest that symptoms present only in 60% of the cases, with the lesions for the rest of the cases found incidentally.12 PPB is often found late on plain film radiographs as a unilateral lung whiteout with a mediastinal shift to the opposite side. Typically, there are no adjacent rib erosions or calcifications. In the majority of cases, the disease is unilateral, but bilateral disease has been reported. In some cases, pleural effusion may be seen.11 Ultrasound is a poor imaging modality for diagnosing PPB as findings are non-specific and may show a large region of consolidation without sonographic air bronchogram. The appearance of PPB on CT scan is variable depending on the histological type of the tumour.8,13,14 Type I lesions manifest as a single cyst or a multicystic lesion (often air-filled). Type II lesions show air- or fluid-filled cavities with possible air-fluid levels along with solid internal nodules. In type III lesions, neoplasms are solid and show low attenuation, with homogeneous or heterogeneous enhancement. On MRI, the tumor manifests as a heterogeneous mass, typically hyperintense on both T1W and T2W sequences.15 A FDG-PET CT scans reveals a hypermetabolic lesion. PET CT is helpful in evaluating metastatic work up. It is also helpful in evaluating tumour vitality and judging the response to neoadjuvant chemotherapy.16Imaging studies have enormous capability on identifying the charactersticis of lung lesions. Usually, PPB appears as a solitary, well-demarcated, peripheral mass that can be large enough to extend beyond 10 cm in size.The differential diagnosis for a chest wall mass identified on imaging of a young child is wide. For type 1 PPB lesions, the differential diagnosis includes other cystic lesions such as bronchogenic cyst, lung cyst, pneumatocele, and pulmonary interstitial emphysema. The differential diagnosis for types II and III PPBs, particularly when they are locally aggressive, includes more common tumours such as neuroblastoma, Ewing’s sarcoma, Askin tumour and rhabdomyosarcoma. However, chest lesions that arise from the chest wall such as Ewing’s sarcoma and Askin tumour usually demonstrate findings of chest wall involvement. Neuroblastoma typically arises in the posterior mediastinum and demonstrates chest wall involvement as rib erosion. Rhabdomyosarcoma can also involve the chest wall.Identifying imaging findings that can make a specific diagnosis more or less likely. Interpetation of imaging exams was important and helped in making the correct diagnosis in this case by identifying the heterogeneousity, low attenuation, the association of pleural effusion and the absence of chest wall invasion. The definitive diagnosis of PPB was made by cytogenic analysis of the tumor cells, which were biopsied under the guidance of CT.Despite being rare, PPB affects mainly young children and can lead to quick clinical detrioration.When a large hemithorax mass is identified in a young child, PPB should be considered in the differential diagnosis.The imaging findings favouring the possibility of PPB on a chest radiograph include large mass lesion with small pleural effusion, contralateral mediastinal shift and lack of chest wall invasion.


Acute bowel ischemia (ABI) can be life threatening with high mortality rate. In spite of the advances made in diagnosis and treatment of ABI, no significant change has occurred in the mortality over the past decade. ABI is potentially reversible with prompt diagnosis. The radiologist plays a central role in the initial diagnosis and preventing progression to irreversible intestinal ischemic injury or bowel necrosis. The most single imaging findings described in the literature are either non-specific or only present in the late stages of ABI, urging the use of a constellation of features to reach a more confident diagnosis. While ABI has been traditionally categorized based on the etiology with a wide spectrum of imaging findings overlapped with each other, the final decision for patient’s management is usually made on the stage of the ABI with respect to the underlying pathophysiology. In this review, we first discuss the pathologic stages of ischemia and then summarize the various imaging signs and causes of ABI. We also emphasize on the correlation of imaging findings and pathological staging of the disease. Finally, a management approach is proposed using combined clinical and radiological findings to determine whether the patient may benefit from surgery or not. There is a correlation between pathologic staging and radiologic findings of ABI.Reversibility–irreversibility of ABI spans a temporal continuum with areas of overlap.Understanding the pathophysiology of ABI can help for better management.Management should be based on the latest stage identified.Acute bowel ischemia (ABI) is defined as bowel injury associated with sudden interruption of blood supply to small or large intestine in an either segmental or diffuse pattern . DespiteClinical presentation, physical examination and laboratory findings are generally non-specific and do not reliably differentiate bowel ischemia from other abdominal emergencies without imaging . PatientDuration of insufficient blood flow is the most important prognostic factor which makes timely diagnosis and surgical intervention the cornerstones of improved outcome . AlthougWith a 93% sensitivity and 96% specificity, multidetector computed tomography (MDCT) scan is widely utilized as the first-line imaging choice to confirm and localize ABI, determine its severity and exclude mimickers . MRI is ABI tends to develop through different stages with distinctive diagnostic features at each stage . CT scanThis review will address various causes and imaging signs of bowel ischemia with emphasizes on correlation of imaging findings and pathological staging of the disease. Finally, a management approach is proposed using combined clinical and radiological findings.Intestinal ischemia develops when blood perfusion is disproportionate to the metabolic demands of the organ. Collateral circulation can protect the bowel from substantial damage when up to 75% of bowel perfusion is lost for 12 h ; however1), midgut  and hindgut , respectively [A solid understanding of vascular anatomy and territories is crucial to identify the areas that are particularly susceptible to infarction from global ischemia. The abdominal aorta gives off three major branches responsible for the arterial blood supply of gastrointestinal tract, namely celiac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA), which perfuse foregut 1), midguectively .Fig. 2BoThe mesenteric venous drainage includes superior mesenteric vein (SMV) and inferior mesenteric vein (IMV), grossly mirroring the arterial system and running alongside the corresponding arteries. IMV drains blood from rectosigmoid and left colon; meanwhile, SMV drains right and transverse colon, ileum and jejunum. Subsequently, SMV and splenic vein (SV) join together to form the portal vein. IMV can drain into splenic vein (SV), SMV or their confluence . In caseAbsence or underdevelopment of vascular connections between two neighboring colonic vascular territories is regarded as “Watershed” areas. Junction of SMA and IMA at the colon’s splenic flexure is known as “Griffith’s point” . There iUnderstanding the pathologic basis of ABI can help to estimate the probability of reversibility and choose the optimal treatment option. The gastrointestinal tract is made up of four layers, which include mucosa, submucosa, muscularis and serosa, from inner to outermost layer. ABI is categorized into 3 stages based on the involvement of each layer.In stage I or the early stage, the damage is only confined to the mucosal layer . The earStage II or the intermediate stage is described as presence of specific pathologic changes  in submucosa and muscularis propria . There aStage III, the late stage, is manifested by transmural bowel necrosis and is developed if blood supply is not eventually restored . EpithelCT images are acquired in supine position from diaphragmatic dome to pubic symphysis covering the entire length of gastrointestinal tract. The protocol consists of unenhanced, arterial and portal venous phases for optimal visualization of hemorrhage, splanchnic vessels and bowel wall. Using unenhanced CT alone is inadequate and results in a delayed diagnosis as well as increased mortality . FollowiPre-contrast imaging is necessary as some important features of ischemia, like vascular wall calcification, hyperattenuating thrombosis and intramural hemorrhage, might be overlooked in post contrast images Fig. . Oral coEarly imaging diagnosis of ABI is often challenging since each individual CT finding is non-specific when observed separately. These include altered bowel wall thickness, attenuation or enhancement along with increased luminal diameter, mesenteric fat engorgement and mesenteric fluid . The latEarly stage: Bowel wall may be unchanged or thickened at stage I. Edema in submucosa and muscularis propria results in hypoattenuated thickened bowel wall, which is the most common imaging feature with a sensitivity of 38–86% and a specificity of 38–72% [f 38–72% , 42. Incf 38–72% . This muf 38–72% . On the f 38–72% , 40. Becf 38–72% . Reductif 38–72% . Differef 38–72% , 45.Intermediate stage Deeper extension of ischemia in stage 2 leads to paralytic ileus and luminal dilatation induced by nervous plexus involvement [olvement . This fiolvement , 41, 45.olvement , 40, 47.olvement .Late stage In the late stage of arterial occlusion, transmural destruction of nerves and muscular layer leads to dilated, fluid or gas filled loops with extremely thinned wall, creating “Paper thin wall” appearance [pearance . Transmupearance . TransmuArterial etiologies are the most prevalent causes of ABI, accounting for 60–70% cases . ArteriaMesenteric arterial emboli (MAE) account for approximately half of all ABI cases . ArteriaMesenteric arterial thrombosis (MAT) is responsible for 20–35% of ABI cases . PatientCT scan findings for both arterial embolus and thrombosis have great similarities. Low-attenuation filling defect on CT angiography or high attenuation intravascular substance on an unenhanced CT scan is a direct sign for arterial embolus or thrombosis, which can lead to “pale ischemia” and cause “paper-thin” bowel wall . The sigAlthough arterial bowel ischemia has a much higher incidence in the elderly men over 70 years old , in younMesenteric venous thrombosis (MVT) accounts for 5–15% of ABI cases with the youngest peak age of onset and significantly better prognosis when compared to the arterial category  . AlthougIn the early stage, the bowel wall is frequently thickened . This fiSalim et al. demonstrated that small bowel wall edema was the independent risk factor associated with bowel resection in a prospective study on 102 patients with mesenteric venous thrombosis . In a stNon-occlusive mesenteric ischemia (NOMI) is responsible for almost 20% of ABI cases  and is cGeneralized vasospasm may be obvious as narrowing of IVC, aorta and mesenteric vessels resulting in decreased enhancement of affected bowel segments and occasionally other organs  . Bowel wDuring the hypoperfusion state, colon is more vulnerable to ischemia than the small intestine . The anaStrangulated bowel is usually emanating from closed-loop obstruction and is responsible for 10% of ABI cases . It is dMixed arterial and venous ischemia are also infrequently seen in association with other conditions including trauma, chemotherapy, irradiation, drug induced, corrosive injury, lead poisoning, iatrogenic, etc.  Figs. 2, 27, 28.The main goal of management is to achieve a prompt diagnosis, specify the best treatment option and reduce mortality in these patients. ABI is a cardiovascular emergency which entails strict management rules identical to those created for acute myocardial or cerebrovascular ischemia . With imThe management of ABI is summarized as “3Rs,” Resuscitation, Rapid diagnosis and Revascularization . InvasivIt is noteworthy that reversibility–irreversibility of the bowel spans a temporal continuum with areas of overlap Fig. . In the Some non-ischemic conditions may have overlapping imaging features. Most notably, pneumatosis intestinalis may be found in any mechanical mucosal injury, increased mucosal permeability, infections, corticosteroid usage, organ transplantation, inflammation, certain pulmonary conditions with alveolar rupture and pneumatosis cystoides coli , 97. DifBowel wall ischemia is sub-classified into three pathologic stages depending on the degree of mural involvement . There are imaging clues that indicate the severity of bowel wall involvement and suggest the pathologic stage. Bowel ischemia may be classified by etiology into the following categories: arterial, venous, non-occlusive mesenteric ischemia (NOMI), mixed arterial/venous and miscellaneous (rare). Imaging provides valuable information regarding the inciting cause. Both the reversibility and imaging stages of ischemia have considerable overlap; however, the management should be based on the latest stage identified. The imaging findings should be interpreted in the context of the clinical picture  and management decisions should ultimately be guided clinically. Decision regarding whether the patient needs surgery or not is the most important question from clinician, which is usually unrelated to the etiology of the ABI since any cause of bowel ischemia may eventually results in a single outcome that is bowel necrosis. Therefore, focusing on the predictive factors of bowel necrosis rather than etiology can better help on the management of ABI cases.


The Video Capsule Diagnostic Imaging is a technique for exploring the digestive tract, particularly the small bowel. It is indicated for any unexplained digestive bleeding or as a means of monitoring intestinal polyposis or inflammatory diseases. This videocapsule is not digestible, and the risk of its retention, symptomatic or not, is not negligible following an inflammatory, anastomatous or tumoral stenosis. This retention or blockage is defined by the presence of the Video Capsule in the digestive tract at least two weeks after ingestion. Surgical approach is considered effective to retrieve the retained capsule, treat the pathology responsible and prevent acute complications.We report the case of retention of a video capsule in a young patient with severe anaemia due to inflammatory polyposis of the small bowl, whose removal required surgery to extract the capsule and resect the segment of the small intestine stenosis by the polyps. •The video Capsule Endoscopy is the most sensitive examination for the detection of inflammatory lesions of the small bowel.•It does not currently allow a biopsy but it is indicated for unexplained or occult digestive bleeding.•Its main limitation is the risk of blockage in a stenosis with or without occlusion.•Surgical approach is considered effective to retrieve the retained capsule, and treat the pathology responsible. Its sensitivity and specificity is close to 90% . AlthougThe purpose of this work is to present a case of retention of a videocapsule at the small bowel treated surgically. the work has been reported in line with the SCARE 2020 criteria .2The patient is 30 years old, with no particular pathological history, followed for a chronic anemia unexplained for 3 months, without externalized digestive haemorrhage or transit disorder, all evolving in a context of conservation of the general state. Clinical examination found a stable hemodynamic patient, with discolored conjunctivae, slight peri-umbilical abdominal tenderness, without palpable abdominal mass or hepatomegaly or splenomegaly. The rectal examination found no bleeding stigma. On the biological check-up, the hemoglobin level was 7g/dl, GMV 70.5μ3, platelets 350000ele/mm3. His haemostasis assessment was correct. eosogastric fibroscopy and colonoscopy were normal. An enteroscanner had objectified a thickening of only a few parts of the small intestine, hence the indication for an exploration by a videocapsule, which had detected a fern leaf lesion at the jejunum proximal substenosing preventing the progression of the capsule beyond. In front of the absence of elimination of the capsule after 15 days of its digestion, without occlusive syndrome, the retention complication was retained which required a surgical extraction.Surgical exploration found a capsule blocked at 1 m from the duodeno-jejunal angle by polyps. The extraction of the capsule was done as well as a complete resection of the polypoid lesion on the bowel. The histological study showed inflammatory polyps with complete resection.The postoperative follow-up was simple, with normalization of hemoglobin levels for a year's decline.3The endoscopic videocapsule has become the reference examination for exploring the lumen of the small intestine. It is mainly indicated for the diagnosis of unexplained digestive bleeding, or in the context of Crohn's disease in the search for mucosal lesions when morphological and endoscopic examinations of the small intestine with biopsies are negative ,6. It isThe main fearsome complication of endoscopic videocapsule is its retention in case of digestive stenosis with or without occlusion. It is therefore necessary to carefully check the patient's history  before proceeding with the placement of the capsule.The International Conference on Capsule Endoscopy (ICCE) defined Videocapsule retention in 2005 as the presence of a capsule in the gastrointestinal tract for at least two weeks requiring medical, endoscopic or directed surgical intervention . It mustThe most frequent causes of this retention are stenosis due to non-steroidal anti-inflammatory drugs, radiation enteritis, intestinal tumors, surgical anastomoses and especially Crohn's disease . Capsule4The endoscopic video-capsule for the small bowel has revolutionized the exploration of the small bowel in the front of unexplained digestive bleeding or suspicion of Crohn's disease, localized exclusively to the small intestine. It represents the reference examination after a normal gastrointestinal endoscopy and colonoscopy. However, retention of the capsule remains one of its main limitations, which sometimes requires surgery to extract it.I declare on my honor that the ethical approval has been exempted by my establishment.None.Taoufik El abbassi:Corresponding author writing the paper and operating surgeon.Wafaa Hliwa writing the paper.Yassine El Berni writing the paper.Salahedine Elmassi writing the paper.Wafaa Badre study concept.M. Rachid Lefriyekh study concept.It's not a study but a case report that why we don't number of registration.Pr Elabbassi taoufik.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.All authors contributed equally to the conduct of this work. They also declare that they have read and approved the final version of the manuscript.The authors declare having no conflicts of interest for this article.


Potential complications of this procedure include subcapsular renal hematoma, pseudoaneurysm, arteriovenous fistula, abscess formation in the psoas muscle, thrombosis of the portal or iliac vein, and-the most disastrous and potentially fatal complication-abdominal aortic aneurysm (AAA) rupture,2.Extracorporeal shockwave lithotripsy (ESWL) is a type of urological intervention used for the treatment of stones smaller than 2 cm located in the renal pelvis or upper portion of the ureter,2, because of calcifications of the arterial walls resulting from atherosclerotic disease, given that the mechanical energy of the shockwaves can disperse up to 12 cm from the focal point; although the intensity of the waves decreases progressively as the distance from the target increases, they can still have a deleterious effect on parietal calcifications. Despite the scarcity of studies on this topic, we believe that advanced age and short distances between vascular parietal calcifications and renal pelvis calculi may be risk factors for AAA rupture during ESWL.Studies have shown that AAA is a potential risk factor for ESWL-induced arterial rupture-6. In a review of the literature, Tse et al. discovered that, among the reported cases of patients with AAA who underwent ESWL, there were no vascular complications in 18, rupture of the AAA occurred in 6, and aortic rupture in a nonaneurysmal calcified aorta occurred in 2. In the present article, we will demonstrate the endovascular correction of abdominal aorta rupture in a patient submitted to ESWL.There is not sufficient scientific evidence to define the safety of ESWL in patients with AAA, a controversial subject in the literature.Symptoms of AAA rupture may include severe low back pain, general malaise, nausea, vomiting, dizziness, and blurred vision. Physical examination may show pallor, hypotension, tachycardia, and a pulsatile abdominal mass. In cases of hemodynamic instability, the patient must first be stabilized, and, when possible, should undergo computed tomography (CT) angiography of the abdomen, which is the imaging modality of choice for the diagnosis and planning of endovascular treatment. Rupture of an AAA is more likely to occur in the retroperitoneal space than in the peritoneal cavity, mortality rates being higher if it occurs in the latter.When diagnosing AAA rupture by CT angiography  and 2, cThe endovascular approach begins in the hemodynamics room, with the patient in the supine position. Ultrasound-guided puncture of the right common femoral artery, by the Seldinger technique, is followed by insertion of a 6 Fr femoral introducer, a stiff guidewire, and a pigtail catheter for aortic angiography, aiming at planning the procedure, which will be involve coverage of the rupture site (pseudoaneurysm) with a coated stent , throughFollow-up evaluation can be performed after one week at an outpatient clinic, and a follow-up CT angiography can be performed after 30 days. Patients should be reevaluated at 12 months after the procedure, with Doppler ultrasound evaluation of the abdominal aorta, iliac arteries, renal arteries, and superior mesenteric artery.