Cleft palate in dogs is a congenital defect that mostly leads to euthanasia of the affected puppy. If an attempt is made to raise the puppy, it is generally fed via an orogastric tube. Here, we describe the management of cleft palate in three puppies  using a customised temporary prosthesis, which allowed the puppies to be bottle-fed and successfully raised by their owners (Cases 2 and 3) and the author (Case 1). The temporary palatal prosthesis was manufactured from a mouthguard intended for human children, which is made of thermoplastic silicone. The preparation procedure was simple and cost-effective. All puppies underwent corrective surgery at 5–6 months of age. After surgery, one of the Boxer puppies showed mandibular mesioclusion, while the other two showed no aberrations. All puppies gained the same amount of weight as their littermates, although the weight gain of the two Boxers was slower than that of their littermates. In summary, this case report describes an easy and effective way to raise puppies with cleft palate until corrective surgery can be performed. Palatoschisis, also known as cleft palate (CP), is a craniofacial defect characterised by an abnormal communication between the oral and nasal cavities and is one of the most common craniofacial defects in dogs ,2,3. BecIn the present report, we describe the successful management of CP using a customised temporary prosthesis in three puppies, and demonstrate an easy and affordable way to raise puppies with CP until corrective surgery can be performed.Case 1 involved a 3-day-old male Boxer puppy that presented at the Clinic for Obstetrics, Gynecology and Andrology of Large and Small Animals with Ambulatory Service of the Justus-Liebig University in Germany. The owner reported that the puppy was very active and continuously suckling. Nonetheless, he did not gain weight, and the owner frequently observed nasal discharge after suckling.®, Royal Canin, Köln, Germany) was offered, the puppy suckled immediately. Although he showed nasal discharge and occasional sneezing, he demonstrated a good appetite. He required a long time to consume the amount of milk necessary for gaining body weight. Because of his good general condition, an attempt at raising him was made and the puppy was assigned to the clinic.On examination, the puppy exhibited a good general condition and was very lively. Intraoral examination revealed CP . The CP Case 2 involved a female Boxer that presented with a congenital palatal defect on the day of birth. The puppy was diagnosed with cleft lip and palate (CLP), or cheilognathopalatoschisis, which was classified as “- - H S H A L” according to the LAHSAL classification, which is a system for classifying clefts . The defCase 3 involved a male Collie that presented with mild bronchopneumonia, which was diagnosed based on a clinical examination, a complete blood count, and an ultrasound of the lungs. This puppy presented at the age of 12 days. The puppy was found to have a continuous hard and soft palate defect, classified as “- - H S H - -“ according to the LAHSAL classification . The def®, Royal Canin, Köln, Germany) with wet dog food , and at 2.5 months of age, they changed the feed to commercial dry dog food , which the puppies could eat without the prosthesis. The puppies showed no difficulty in drinking water. A temporary prosthesis was crafted from a mouthguard intended for human children , which is made of thermoplastic silicone and can be reformed by heating in hot water. About 1–2 cm of the mouthguard was cut off a and pla®, 6 mg per inhalation, Boehringer Ingelheim, Ingelheim am Rhein) to clear the upper respiratory tract. The puppy in Case 3 received amoxicillin–clavulanic acid for 10 days  for the management of bronchopneumonia.All puppies were treated with frequent inhalation of ambroxol during the first 2 weeks . Although the puppies showed good food intake, the two Boxer puppies exhibited slower body weight gain than their littermates, while the Collie developed at the same rate as his littermates.The puppy in Case 1 was raised by one of the authors in isolation from its littermates, while the other two puppies were raised along with their littermates by their respective owners. Both of them suckled from their mothers without the prosthesis; however, there was no effective milk intake. All puppies were fed by bottle with the prosthesis in place. The puppy in Case 2 showed signs of pneumonia at approximately 6 weeks of age, but recovered and developed well after the treatment with amoxicillin–clavulanic acid (SynuloxBetween 5–6 months of age, all three puppies  underwenAlthough CP is one of the most common congenital craniofacial defects in dogs, most puppies are euthanised or die because of aspiration pneumonia. Corrective surgery can be performed at an age of about 4–6 months . Until tIn summary, we described the successful management of puppies with CP using a temporary customised prosthesis, which allowed them to be bottle-fed and successfully raised until corrective surgery could be performed. The findings from this report show that a puppy with CP can be raised with little effort and at low cost, thus encouraging owners to seek appropriate treatment for such puppies instead of considering euthanasia.


Epstein Barr virus (EBV) is a human herpes virus 4, transmitted through intimate contact between susceptible persons and asymptomatic EBV shedders. It usually presents with fever, pharyngitis and lymphadenopathy. Majority of individuals with primary EBV infection recover uneventfully. Acute Acalculous Cholecystitis (AAC) is usually seen in hospitalized and critically ill patients with major trauma, shock, severe sepsis, total parenteral nutrition and mechanical ventilation.We report a 25-year- old woman presented with acute Epstein-Barr Virus (EBV)infection and hepatobiliary iminodiacetic acid (HIDA) scan confirmed presence of Acute Acalculous Cholecystitis (AAC). Conservative management was advised initially, but she had a laparoscopic cholecystectomy due to intolerable abdominal pain.AAC is a rare complication of acute EBV infection and it is usually managed conservatively, although our patient had laparoscopic cholecystectomy due to intolerable abdominal pain. •Acute Acalculous Cholecystitis (AAC) is a rare complication of acute EBV infection.•AAC should be suspected in patient with acute EBV infection, presenting with abdominal pain.•Management is usually conservative without surgical intervention. It usually presents with fever, pharyngitis and lymphadenopathy . Majorit2We report a 25-year- old woman who presented with fever T 38.6C, sore throat, abdominal pain, nausea, vomiting and anorexia. On physical exam, she had right upper quadrant abdominal tenderness without signs of lymphadenopathy. She was in her usual state of health as an average healthy woman with medical history of polycystic ovarian syndrome, gastroesophageal reflux disease and mild intermittent asthma until ten days prior to admission when she had headache, fever, cough and muscle aches. Her primary care physician prescribed her a prophylactic course of Oseltamivir 75 mg twice daily for five days and after the third day of treatment, her symptoms continued to worsen with development of abdominal pain and she walked into our emergency room. Initial investigations showed: negative Flu/RSV by PCR, WBC count , lymphocytes count , atypical lymphocytes , conjugated bilirubin , alanine aminotransferase , aspartate aminotransferase , alkaline phosphatase , positive EBV VCA IgM antibody, negative EBV VCA IgG antibody and high EBV count by PCR  which confirmed presence of acute EBV infection.On day 2 of admission, increasing intensity of abdominal pain with worsening of liver function, warranted further investigations: conjugated bilirubin , alanine aminotransferase , aspartate aminotransferase  and alkaline phosphatase . Abdominal ultrasonography was unremarkable and abdominal computed tomography showed mild gallbladder distension, mild gallbladder wall thickening (2.5 mm) and mild pericholecystic fluid collection with no layering stones, sludge or biliary ductal dilation. Hepatobiliary iminodiacetic acid (HIDA) scan showed non-accumulation of the isotope within the gallbladder which confirmed the presence of AAC , Fig. 1Fig. 1.FiOn day 4 of admission, abdominal pain was worsening and her blood pressure dropped into 80/50 mm/Hg. Conservative management was advised initially, but her abdominal pain was intolerable so she opted for a laparoscopic cholecystectomy. Intraoperatively, the gall bladder was found to be edematous, markedly inflamed and no gallstones were found. The final pathology report of the removed gallbladder showed AAC. She was given a single dose of 2 gm of intravenous Cefazolin preoperatively. She was not given glucocorticoids or acyclovir. Her symptoms improved after surgery and she was discharged on the fifth day of admission. Liver function returned to normal levels two weeks after surgery.3Although majority of cases with primary acute EBV infection recover without sequelae, few cases of AAC have been reported as a complication of primary acute EBV infection . Kottana4AAC is a rare complication of primary acute EBV infection which is usually managed conservatively without surgery, however, our patient had laparoscopic cholecystectomy due to intolerable abdominal pain. AAC should be suspected in patients with acute EBV infection, presenting with abdominal pain.Our institution does not require ethical approval for publishing case report.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.First Author: Kamal Rezkallah.Corresponding Author: Kamal Rezkallah.Kamal Rezkallah: Literature review, data collection, original draft writing and final approval of the draft to be submitted.Khlid Barakat, Abdurraheem Farrah, Shesh Rao, Monica Sharma, Shyam Chalise and Teresita Zdunek: Literature review, draft revising and final approval of the draft to be submitted.None.None.Kamal Rezkallah.Not commissioned, externally peer reviewed.Black and White.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.


Hoffa's fat pad can be affected by a variety of tumors. Schwannomas are benign and typically solitary neoplasms of the peripheral nerve sheath; they are made up of the neoplastic Schwann cells and are usually located eccentrically. Malignant schwannomas are extremely uncommon. Here we report a case of an intra-articular schwannoma of the knee. A 54-year-old man presented with a painful lump in the medial aspect of the knee. Magnetic resonance imaging revealed a well-circumscribed intra-articular mass, which was later diagnosed as an intra-articular schwannoma based on biopsy findings. The infrapatellar Hoffa's fat pad (HFP) is an intracapsular but extrasynovial structure located in the knee joint. Disorders of the HFP are a common cause of anterior knee pain.Benign schwannoma is the most common tumor of the peripheral nerves. Schwannomas are usually encapsulated, circumscribed, solitary, and located eccentrically and composed of the Schwann cells of the peripheral nerve sheath. Malignant transformation of schwannomas is extremely rare and accounts for less than 1% of all cases.Histologically, schwannomas have two distinctive areas of high and low cellularity called Antoni A and B areas, respectively. Schwannomas are usually entirely composed of Antoni A areas, where spindle cells are closely packed.To the best of our knowledge, only one case of intra-articular schwannoma of the knee has been reported. Thus, in the current report, we aim to describe a rare and interesting case of an intra-articular schwannoma of the knee to increase its awareness in the orthopaedic community.A 54-year-old Caucasian man with a painful lump on his left leg and a medical history of arterial hypertension visited the orthopaedic department. He denied any history of trauma prior to symptom onset. His clinical examination revealed a firm mass in the proximal medial aspect of his left leg and a reduced range of extension. He experienced increased pain with passive and active dorsiflexion. Magnetic resonance imaging (MRI) of the leg was performed for further evaluation . A massMost solitary HFP tumors are benign. In 2011, Dean et al presented 19 patients with benign tumors of the intra-articular ganglia with pigmented villonodular synovitis as the most common diagnosis.The present case report describes the discovery of an intra-articular benign tumor of the peripheral nerves. Schwannomas usually occur in the fourth and fifth decades of life and have a female predilection of 1.6:1.Evaluation of the patient's symptoms, history taking, and physical examination suggested the presence of a tumor. Microscopic analysis helped to confirm the diagnosis of a schwannoma. The patient's preoperative plain radiographs and MRI were assessed. Consequently, radical surgical excision was proposed and performed based on the patient's symptomatology.Although radiography should be initially performed to rule out the possibility of malignant tumor, MRI remains the imaging technique of choice for accurate diagnosis. Regarding solitary tumors, they are frequently symptomatic, and excellent outcomes can be achieved using open excision, which ensures that solitary HFP tumors are completely removed.This is the second reported case of a larger intra-articular schwannoma of the knee since 1994. Considering the rarity of this tumor, the present report is a great addition to the limited literature.


Pseudomyxoma peritonei (PMP) is a rare and life-threatening cancer of the abdominal peritoneum. Symptoms can be non-specific and ignorable for several years such that most cases are diagnosed during explorative surgery. The cornerstones of diagnosis and effective management are heightened awareness and clinical suspicion, timely recognition, and early referral to a specialist center for work-up and cytoreductive surgery. We report an interesting case of a patient with PMP who had successful cytoreductive surgery and heated intraperitoneal chemotherapy. Peudomyxoma peritonei (PMP) is a poorly understood and rare tumor of the abdominal peritoneum. The diseased peritoneum produces an excessive amount of mucinous fluid which gradually fills the peritoneal cavity to the point of compressing vital organs, such as the pancreas, spleen, stomach, kidneys, liver, and the colon . The estA 69-year-old man attended the emergency department having had severe acute onset left-sided abdominal pain. The pain had resolved before attendance. Further history taking revealed that he had noticed increasing abdominal girth over the previous 6 months. He had no past medical history of note and was not on any regular medication. He was a non-smoker.On physical examination, the patient appeared generally well. He was hemodynamically stable and apyrexial. Abdominal examination revealed a soft non-tender abdomen.Blood results demonstrated mild normocytic anemia but normal liver and kidney function. The C-reactive protein was slightly raised Table .A chest and abdominal x-ray did not reveal any abnormal findings. A computerised tomography scan revealed a large amount of free fluid within the peritoneal cavity with high attenuation (20-27 Hounsfield Units) Figure .A follow-up ultrasound scan of his abdomen revealed extensive multiloculated ascites which contained extensive internal debris. The appearances were suggestive of pseudomyoxma peritonei Figure .Tumor markers results indicated raised carcinoembryonic antigen (CEA) and cancer antigen 19.9 (CA19.9) levels Table .Laparotomy revealed large volumes of multiple cystic collections of mucinous material from a perforated primary appendix tumor. The liver, spleen, and part of the large bowel were affected  and the small bowel serosal surfaces were lightly coated with mucin. The patient underwent complete cytoreductive surgery, appendectomy, splenectomy, and HIPEC . A histological diagnosis of low-grade appendiceal mucinous neoplasm with low-grade mucinous carcinoma peritonei was made. The patient is being followed up with yearly scans.Pseudomyxoma peritonei was first described in 1842 by Karl Rokitansky and later described by Werth in association with a mucinous carcinoma of the ovary in 1884 and subsequently described by Frankel in association with an appendiceal cystic tumor in 1901 [Patients with PMP are usually asymptomatic for many years before diagnosis but the commonest symptoms are abdominal distension or increase in abdominal girth with non-specific abdominal pain during the advanced stages of the disease. Other symptoms and signs depend on organ involvement or compression.Computed tomography (CT) scan is the best imaging technique for diagnosis and staging. The pathognomonic feature is the appearance of areas of low attenuation with islands of high attenuation due to solid elements within mucinous material. Scalloping of visceral surfaces especially liver and spleen distinguish this from fluid ascites . The tumOptimal treatment involves a combination of complete tumor excision by complex surgical peritonectomy (cytoreductive surgery) and HIPEC using cytotoxic medication to target residual microscopic disease .Acute abdominal pain has been a noted symptom in a fifth of cases of PMP . The patIn conclusion, we have described a patient who developed pseudomyxoma peritonei in the setting of a perforated appendiceal tumor. The presentation was acute with the only symptom being abdominal pain. As with other cases, the diagnosis was made histologically after surgical treatment. The cornerstones of diagnosis and effective management are heightened awareness and clinical suspicion, timely recognition, and early referral to a specialist center for work-up and cytoreductive surgery. We hope that this case will not only add to the existing literature but also contribute to the characterization and management of this rare disease.


Jejunal diverticulosis is a rare intestinal pathology with an incidence of 0.5–1%. While most cases are asymptomatic, 30–40% of the cases may become symptomatic with chronic abdominal pain, malabsorption, hemorrhage, diverticulitis, obstruction, abscess formation and, rarely, diverticula perforation. It is generally localized on the mesenteric side and it develops from the entry points of the vessels into the jejunum.Case 1 – A 36-year Case 2 a 75 old female patient patient was admitted to the emergency department with the complaint of widespread abdominal pain, Case 1 8 diverticules, one with diverticule perforation, was observed in the jejunum segment between the 50th and 90th centimeters after the Treitz Ligament. Case 2 – In the diverticulum 100 cm distal from the Treitz ligament, mesenteric perforation area of 4–5 mm were observed.Segmentary small bowel resection and side-by-side anastomosis were performed in these cases. In the histopathological examination, the Diverticula were seen to be pseudodiverticullar lesions including herniation of the mucosa and submucosa.Jejunoileal diverticulosis is a rare disease with life-threatening complications such as perforation, obstruction and bleeding, it is usually asymptomatic or presents with nonspecific symptoms. It should be considered in the differential diagnosis of acute abdomen. This work is reported in line with the Preferred Reporting of Case Series in Surgery (PROCESS) Guidelines criteria .2A 36-year-old female patient was admitted to the emergency department with the complaint of widespread abdominal pain, nausea and vomiting. Physical examination revealed widespread defense, rebound and sensitivity in all quadrants. Temp: 37.6’C, Pulse: 114/min, TA: 110/80 mmHg, WBC: 15,3. In the patient, who was operated on for endometriosis 15 days prior to her complaints, direct abdominal X-ray was performed for determining acute abdomen etiology and it revealed free air under the diaphragm. Computed tomography (CT) imaging performed to clarify the cause completely revealed free air around the liver, free fluid compatible with intense collection, and edema in the mesentery . The pat33, Hgb: 11.1 g/dl, Plt: 174.000. She had a history of Atrial Fibrillation and Heart Failure. On posterior anterior (PA) chest radiography, free air under the diaphragm was not seen. Abdominal CT imaging showed edema in the small bowel loops in the left upper quadrant. The patient was operated with the diagnosis of acute abdomen. From the 70th to 120thcm from the Treitz ligament, a large number of diverticular cysts with mesenteric origin were observed  (6–7). Non-Meckel small bowel diverticular disease has a prevalence of 0.3–1.3% in postmortem studies, 0.5–1.9% in contrast-enhanced imaging modalities, and is more common in older patients [Duodenum is the most common localization of small bowel diverticular disease; the incidence of jejunum and ileum is less, with 0.7–1% . The incThe etiology of jejunal diverticulosis is unknown and is thought to be caused by a combination of abnormal peristalsis, intestinal dyskinesia and increased intraluminal pressure factors. It is generally localized on the mesenteric side and it develops from the jejunal entry points of the vessels .Uncomplicated cases are usually asymptomatic. It may show symptoms such as nausea, vomiting, epigastric and periumbilical abdominal pain. Complications such as diverticulitis, bleeding, intestinal obstruction and perforation occur in 30% of patients with jejunal diverticulosis . Lobo etJejunal diverticulosis gives a bullion-like appearance on the barium x-ray . AlthougMost of the complications of jejunoileal diverticulosis requires surgical treatment. Surgical treatment of excision of simple diverticula is not recommended because of the risk of postoperative intestinal leak, sepsis and death; intestinal resection and anastomosis should be preferred . In the In the differential diagnosis of jejunal diverticulosis perforation, Crohn's disease, small intestinal neoplasm, foreign body trauma, and colonic diverticulitis perforation should be considered ,19.Jejunoileal diverticulosis is a rare disease with life-threatening complications such as perforation, obstruction and bleeding, usually with asymptomatic or nonspecific symptoms. It should be considered in the differential diagnosis of abdominal pain and acute abdomen.We have no supportive funding.I certify that this kind of manuscript does not require ethical approval.Written informed consent for publication of his clinical details and clinical images was obtained from the patient.Uğut topal.-Ahmet gökhan sarıtaş study concept, writing the paper, final decision to publish, data collection.İsmail cem eray, Kıvılcım erdoğan and Kubilay dalcı. - study concept, data collection.Atılgan tolga akçam İsmail cem eray,Kıvılcım erdoğan and Kubilay dalcı. - data collection and analysis.We registered our study with the Research Registry. Our unique identifying number is: research registry 5107.Ahmet Gökhan Sarıtaş, İsmail Cem Eray.Not commissioned, externally peer-reviewedNo conflicts of interest were declared.


Dysplasia epiphysealis hemimelica is a rare osteocartilaginous overgrowth syndrome of bone epiphysis, mostly encountered in the lower limbs of immature skeleton patients. We report a case of proximal humerus presentation in an adult male, with neither articular involvement nor clinical dysfunction. This case highlights the importance of stratification into intra- and extra-articular lesions, as this distinction ultimately influences both symptoms and treatment outcome. In addition, the case highlights the importance of specific imaging modalities, such as CT and MR images, which provide excellent anatomic location of the lesion, adequate extension of cartilaginous components, exact status of articular cartilage, and accurate assessment of neighboring structures, such as vessels, nerves, ligaments, tendons, and muscles. The imaging features are described, the relevant literature is reviewed, and salient features are discussed. Dysplasia epiphysealis hemimelica (DEH) is a rare disease of unknown etiology, characterized by the development of an osteocartilaginous tumor in any bone epiphysis or epiphyseal equivalent . The incAlthough benign, DEH can have cosmetic and functional manifestations, such as clinical deformities or masses, inability to wear certain shoes, and mechanical articular impairment , 7, 8. IThe patient is a 58-year-old man that presented with an insidious history of intermittent left shoulder pain, which worsens after vigorous physical training. He denied any suspicious traumatic injury over the left shoulder girdle. Clinical examination revealed no gross deformities or muscle atrophy on the left shoulder comparative to the contralateral upper limb. The range of motion of the left shoulder was well preserved with functional shoulder symmetry . PalpatiRadiographs were obtained, demonstrating abnormal morphology of the left humerus head, characterized as an anteromedial exostosis arising from the epiphysis of this bone. There was no cortical discontinuity, periosteal reaction, calcified matrix, or articular incongruity. In addition, there were no signs of AC disease, although there was slight proximal migration of the distal part of the left clavicle, compatible with a Rockwood and Neer grade 2 AC dislocation .The initial diagnosis was DEH and he was asked multislice computed tomography (CT) and magnetic resonance (MR) images. CT showed an ossified mass in the inferomedial aspect of the proximal humerus epiphysis with no articular or soft tissue involvement .T1-weighted, T2-weighted, and STIR MR images of the left shoulder revealed the inferomedial mass projecting toward the inferior capsular recess, with sharpening of the articular cartilage of the humeral head, but no signs of osteoarthritis (OA). No foci of calcification or soft tissue involvement was noted .The lesion was judged to be localized to the lesser tuberosity and therefore was classified as extra-articular type B1 , according to Clarke's classification system . CuriousBiopsy was not performed as imaging exams were very conclusive, showing typical alterations of DEH in the growth of the proximal humerus epiphysis. Patient was managed with analgesics and physical therapy protocol, including extracorporeal shock wave therapy (ESWT), and oriented to temporarily reduce overhead and across-body exercises. AC joint symptoms completely disappeared and he fully returned to his previous level of physical activity. Patient is periodically followed up without any recurrence of the symptoms on this shoulder.Although it has been described as a rare developmental disorder, recent research has greatly advanced our understanding of the pathobiology and articular involvement of DEH. Erroneously described as an osteochondroma or osteochondroma-like lesion despite its epiphyseal location, some studies demonstrated that DEH lesions differ pathologically from osteochondromas , 15. In Maturation of a DEH lesion leads to a large asymmetric overgrowth of the epiphyseal cartilage and can restrict joint motion and produce mechanical pain , 6–8. ThRegardless of DHE stratification into intra- or extra-articular lesion, total resection of the mass is one of the most common described interventions in immature skeletons , 7. MassDifferently from other adult-presenting cases, our patient was found to have an extra-articular DEH lesion, with no signs of OA. It is possible that the inferomedial projection of the mass toward the inferior capsular recess but not to the glenohumeral joint reduced the risk of articular cartilage involvement, preserving joint motion and shoulder girdle function. Moreover, it is possible that rotator cuff structures were also preserved due to the inferior location of the tumor, as demonstrated by the MR images. In general, because of the natural history of DEH, it is believed that asymptomatic lesions can be observed, mainly after physis is closed, as in our patient , 2.In summary, DEH is a rare osteocartilaginous overgrowth syndrome of bone epiphysis or epiphyseal equivalent, ultra-structurally and genetically distinct from osteochondroma, mostly encountered in the lower limbs of immature skeleton male patients. We report the case of a proximal humerus presentation in an adult male, with neither articular involvement nor clinical dysfunction. The case raises awareness on the stratification into intra- and extra-articular lesions, which ultimately influences both symptoms and final outcome. In addition, the case highlights the importance of specific imaging modalities, such as CT and MR images, which provide excellent anatomic location of the lesion, adequate extension of cartilaginous components, exact status of articular cartilage, and accurate assessment of neighboring structures, such as vessels, nerves, ligaments, tendons, and muscles , 10.


Transomental hernias are very uncommon form of internal hernias. Occasionally they may be seen in present clinical practice after bariatric surgery. Yet, this type of internal hernia remains mostly incidental and enigmatic in its presentation.We present a case of transomental hernia that caused subacute small bowel obstruction in a patient with no past history of any surgical procedure, i.e. in a virgin abdomen.CT Scan of the abdomen revealed the presence of transomental hernia and it was addressed by laparoscopic surgery and an uneventful postoperative outcome.Transomental Hernias can be present in virgin abdomen also. Its presence should be considered in all suspicions of internal hernia occurrence even though they are commonly known to be associated with bariatric surgery, liver surgery, etc. They are relatively uncommon clinical conditions that involve small bowel loops and occur through either congenital or acquired defects of attachment of various peritoneal folds. Subtypes include paraduodenal (53 %) and pericecal (13 %) hernias which are the most common, followed by the hernias through the foramen of Winslow (8 %), the transmesenteric (2 %) and the transomental hernias (1 %) .Transomental Hernias are the rarest type of internal hernias. Occasionally congenital in a minority of paediatric cases, they are most often iatrogenic. Indeed, most transomental hernias occur as a result of previous abdominal surgery, mainly after Roux-en-Y gastric bypass. However, senile atrophy of the omentum may lead to this rare type of internal hernia, even in patients without a past surgical history.Herein, we report a case of transomental hernia that presented as small bowel obstruction in a virgin abdomen and which was treated successfully in our hospital. The treating hospital is the largest military government hospital of the country and also a tertiary referral centre .Fig. 1TrThis case report has been reported in line with the SCARE criteria .2A 55 year male patient came to the emergency department with complaints of sudden onset vomiting and abdominal pain since 2–3 days. The abdominal pain was generalized and colicky in nature. There were no bowel symptoms and no urinary symptoms. This was the first time he had experience this type of pain and he had no other medical or surgical history. The patient’s CT Scan of abdomen revealed incomplete small bowel obstruction. The patient had leukocytosis and neutrophilia on blood picture.Partial obstruction not responding to bowel rest prompted surgical intervention. Laparoscopy revealed a transomental hernia with part of ileum herniating in the omental defect close to the transverse colon. The obstructed loop of small intestine in hernia was reduced and defect was deroofed. After ensuring bowel viability, the abdominal cavity was inspected for other herniae and no other site of obstruction was found. Patient was kept nil orally for 8 h and then gradually shifted to regular diet. The patient was discharged on second post operative day.Patient was followed up in the surgical clinic after 3 weeks postoperatively and has never had similar complaints till date. The surgery was performed by the consultant general surgeon of the unit and also the first author in this case presentation.3Openings of internal hernias can be normal (foramen of Winslow), paranormal , or abnormal  with respect to the routine anatomy of the abdominal cavity ,3. The oTransomental Hernias(TOH) are exceptionally rare, commonly cited to account for roughly 1–4 % of all internal hernias, although this may be an underestimate . In theiTransomental hernias are generally reported in patients aged over fifty . In manyIn children, congenital transomental hernias are common. The males to female ratio is around 2 to 1 . In chil-Type A ,-Type B -Type C .Yamaguchi  classifiTransomental hernias are diﬃcult to diagnosis. Clinical manifestations are not specific and are similar to acute small bowel obstruction. They include nausea, vomiting, abdominal pain, distended abdomen, and constipation. Compared with other types of internal hernias, patients with transomental hernias present more frequently with strangulation of the small bowel. In most cases, a gangrenous bowel is present at the exploratory laparotomy . For thiAbdominal CT scans are helpful for diagnosis. Abdominal CT scans may reveal dilated small bowel loops with a “beak sign,” which is a triangular configuration of the transition zone between the proximal dilated bowels and the herniated bowel segments or between dilated, herniated bowel segments and distal, collapsed bowel segments .CT might also reveal a “whirl sign,” where swirling pattern of the mesenteric vessels, engorged mesenteric vessels with a large impact on the surrounding organs and bowel wall thickening are seen .In addition, a transomental hernia should be suspected if the dilated small bowel loops are localized in the lesser sac  and the neck of the hernia orifice is seen as mesenteric vessels passing through the omental defect . HoweverHowever, similar to its clinical presentation, the radiographic presentation of a TOH is non-specific and the condition is easily misdiagnosed ,27. In aWhile TOHs occur in both children and adults, they are most often seen in patients over the age of 50 years . The herInternal hernias harbor a high mortality rate, because of gangrene among other complications ,25. As s4Internal hernias need high index of suspicion in all cases presenting with small bowel obstruction and classical radiological signs can guide towards its diagnosis. Even without risk factors such as previous abdominal surgery, trauma or peritoneal inflammation; the possibility of bowel obstruction secondary to the internal hernia, esp. transomental hernias should be considered.Surgical treatment based on high clinical suspicion can reduce the risk of complications and postoperative mortality in patients with a transomental hernia.No sponsors of any kind for the case report.Case reports exempt from ethical approval from institution.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 request1Dr. Latifa Al Buainain - Consultant in general surgery and primary surgeon involved in the treatment of the patient’s condition. Responsible for contribution to the manuscript of the case report.2Dr Kaundinya Kiran B - Chief Resident in general surgery and assistant surgeon involved in the treatment of the patient’s condition. Responsible for contribution to the manuscript of the case report and corresponding author for journal submission.3Dr Faizal Hammed N - Chief Resident in general surgery and assistant surgeon involved in the treatment of the patient’s condition. Responsible for contribution to the manuscript of the case report.N.A.Dr Latifa Al Buainain - guarantor who accepts full responsibility for the work and the conduct of study, has access to the data, and controls the decision to publish.Not commissioned, externally peer-reviewedNo known conflicts of interest.


She was non-febrile, and vital signs were stable. Abdominal examination revealed distension and diffuse tenderness. Blood analysis on admission showed increased total white blood cell count  demonstrated a heterogeneous right adnexal mass measuring 57 × 53 mm with fatty components and calcification Figure , arrow, Accordingly, the patient underwent laparoscopic surgery the day after admission, which confirmed the radiological findings. Right ovarian cystectomy and peritoneal lavage were performed. The patient recovered well.Mature ovarian teratoma, commonly called dermoid cyst, is the most frequent benign tumor in premenopausal woman. It is a germinal tumor composed of well-differenciated derivations from at least two of the three germ cell layers. Ectodermal tissue is invariably present. Ovarian teratomas are bilateral in 8% to 15% of cases.This condition is usually asymptomatic but complications such as adnexal torsion, rupture, malignant transformation, or infection may occur. Spontaneous rupture is a rare complication, with an estimated incidence of 0.3 to 2.5%. Discharge of the sebaceous content into the abdominal cavity irritates the peritoneum and may lead to aseptic peritonitis, occurring in less than 1% of the cases [Mature ovarian teratomas have a wide spectrum of radiological presentation. The typical radiologic finding is intratumoral fat (in more than 90% of the cases). The most common ultrasound finding is a cystic mass with a densely echogenic protuberance (known as Rokitansky nodule) projecting into the cystic lumen; this nodule often contains tooth, hair, bony structures or sebaceous components. Some sonographic signs, such as tip-of-the-iceberg sign (only a part of the lesion is visible due to posterior acoustic shadowing) and dot-dash sign (multiple thin echogenic bands due to hair), help for the diagnosis. Computed tomography (CT) and magnetic resonance imaging (MRI) have excellent sensitivity and specificity, and CT is particularly helpful in bringing out tiny calcifications.Ruptured ovarian teratoma can be suggested when demonstrating discontinuity of the cyst wall, when a flattened or distorted tumor shape are noted in the presence of ascites and extratumoral fatty nodules. CT is very sensitive for detection of intraperitoneal fatty nodules, frequently around the liver surface.


Abdominal compartment syndrome (ACS) is associated with mortality in patients with critical illness such as severe acute pancreatitis, but it remains unclear whether decompressive laparotomy for ACS can improve the prognosis of patients.A woman in her 60s visited our hospital because of upper abdominal pain. On the basis of her laboratory data and abdominal contrast-enhanced computed tomography findings, acute gallstone pancreatitis was diagnosed. She underwent endoscopic sphincterotomy for the removal of the common bile duct stone. Then, a drainage tube was placed in the bile duct. However, on the 5th hospital day, her intra-abdominal pressure increased to 22 mmHg and renal dysfunction was observed, which led to the diagnosis of ACS. As intensive medical treatments did not improve her ACS, she underwent decompressive laparotomy on the 9th hospital day. Postoperatively, her laboratory data and intravesical pressure improved, and she was discharged from the hospital after abdominal closure, continuous drainage, and antibiotic therapy.As the effectiveness of decompressive laparotomy for ACS has not been established, this treatment indication remains controversial. Decompressive laparotomy is considered useful for the management of ACS, if it is performed at an appropriate time, as in the present case. The incidence of abdominal compartment syndrome (ACS) resulting from severe acute pancreatitis has been reported to be 4–27% –3. The mAs the effectiveness of decompressive laparotomy for ACS has not been established, this treatment indication remains controversial. In the present case, we experienced that decompressive laparotomy for ACS resulting from severe acute pancreatitis was very effective.A woman in her 60s visited our hospital because of upper abdominal pain. She had a history of appendicitis and cholelithiasis. She was diagnosed with acute gallstone pancreatitis based on her laboratory data and abdominal computed tomography (CT) findings.9/L, hemoglobin level of 14.0 g/dL, and platelet count of 316 × 109/L. Red blood cell count and serum creatinine level were within the normal range. Serum amylase and serum lipase levels were elevated to 2313 U/L and 868 U/L, respectively. Other blood tests showed mild elevations in the biliary enzymes as follows: aspartate aminotransferase 29 U/L, alanine aminotransferase 55 U/L, alkaline phosphatase 654 U/L, γ-glutamyl transpeptidase 168 U/L, and total bilirubin level 0.8 mg/dL. Arterial blood gas analysis was normal. Abdominal contrast-enhanced CT  and a protease inhibitor (ulinastatin) was started. She underwent endoscopic retrograde cholangiopancreatography for common bile duct stone removal. Endoscopic sphincterotomy was performed, and a drainage tube was placed in the bile duct.On the 2nd hospital day, her laboratory data worsened, and abdominal contrast-enhanced CT showed poor contrast of the pancreas, which led to suspected pancreatic necrosis being suspected, and spread of inflammation around the pancreas  [Currently, no clear guidelines have been established for the indication of surgical intervention for patients with ACS due to severe acute pancreatitis. Further studies are required to clarify which cases are appropriate for surgical intervention. Some reports show that early decompression may improve survival. An analysis of 26 ACS patients with severe acute pancreatitis who underwent surgical decompression at a tertiary care hospital showed a decrease in mortality when surgery was performed within 4 days of disease onset (18% vs. 100%) . HoweverP = 0.9) . Boone eP = 0.9) . The decP = 0.9) . Thus, tP = 0.9) . These sAs the effectiveness of decompressive laparotomy for ACS has not been established, the indication of this treatment remains controversial. Decompressive laparotomy is considered useful for the management of ACS if performed at an appropriate time, as in the present case.


This is a case report of a 57-year-old woman who presented with abdominal pain and vomiting over a period of two months. Upper gastrointestinal endoscopies and biopsies were inconclusive, while abdomen computed tomography (CT) scan revealed a large mass arising from the pyloric antrum measuring about 6 × 4.8 cm imitating gastrointestinal stromal tumor (GIST). The patient underwent a laparotomy, and the tumor was totally resected with well-defined borders. The histopathological analysis revealed the mass to be an inflammatory fibroid polyp (IFP). Inflammatory fibroid polyp (IFP) or Vanek's tumor is a rare benign lesion of the gastrointestinal (GI) tract, first described by Vanek in 1949 as eosinophilic submucosal granuloma –4. ThereIFPs usually present in the 5th to 7th decade of life, and children are rarely affected. A familial relationship has also been described .IFPs represent less than 1% of all gastric polyps and can be localized anywhere in the gastrointestinal tract but more frequently affect the gastric antrum 66-75%) [5% [7]. TThis report describes a case of a gastric Vanek polyp, which was surgically completely resected and finally diagnosed with histopathological examination of the resected specimen.A 57-year-old woman presented to the emergency department with acute abdominal pain and nausea. She reported a two-month history of vomiting, postprandial epigastric pain, and weight loss. Past medical history included osteoarthritis, arterial hypertension, and hypothyroidism.On physical examination, the abdomen was soft and there was no sign of peritonitis. Laboratory studies at admission showed neutrophilic leukocytosis, increased C-reactive protein (CRP), and anemia. Serum electrocytes were within normal limits, while urine examination was clear. No abnormal findings were detected on chest and abdomen radiography. The ultrasound  revealed a hypoechoic construction with a diameter of 5.6 cm, located at the pyloric antrum.The patient underwent upper gastrointestinal endoscopy twice, and histopathological examination of biopsy specimens was performed. The lesion appeared to be approximately 6 cm in diameter, obstructing the pyloric antrum and arising from the submucosa or deep mucosa, with well-defined borders Figures . All bioAn abdominal CT scan with administration of oral contrast was performed. It demonstrated a large intraluminal soft tissue mass arising from the pyloric antrum, measuring 6 × 4.8 cm with well-defined borders .Laparotomy was performed. Through gastrotomy, a propyloric tumor obstructing the antrum was discovered and the lesion was totally excised with macroscopically clear margins. After frozen section biopsy had been performed, the tissue was determined to be suggestive of gastrointestinal stromal tumor (GIST), and the surgery was completed with the occlusion of the gastrotomy. The postoperative course was unremarkable, and the patient was discharged after 8 days in good condition.Postoperative macroscopic examination of the specimen showed a firm 5 × 4.5 × 4 cm mass partially covered with gastric mucosa. Histopathological analysis showed a myofibroblastic tumor with inflammatory infiltration comprising mainly eosinophils. Among the fibroblasts, blood vessels with concentric arrangement of tumor cells were conspicuous. The benign nature of the mass alongside its submucosal location could not cause easily vessel rupture, explaining the absence of gastrointestinal bleeding despite the size of the finding.IFPs are rare nonneoplastic lesions arising from the submucosa of the GI tract. Most frequently, they are localized in the gastric antrum. Other less common sites are the other gastric segments, the small bowel, the colon region, the gallbladder, the esophagus, the duodenum, and the appendix .Helicobacter pylori infection is a possible etiology [As far as the etiology of IFP is concerned, an abnormal inflammatory response is suspected to be the trigger of this condition, but its mechanical, chemical (such as bile reflux), or biological pathways remain unknown. Some publications suggest that etiology , 8, 9.IFPs are often asymptomatic and are diagnosed incidentally on surgical, interventional, or imaging investigations. When symptomatic, the clinical picture is determined by the anatomic location . PatientEndoscopically, they appear to be firm, solitary, and well-circumscribed lesions, often ulcerated, deriving from the submucosal layer. Unfortunately, endoscopic biopsies are inconclusive for the diagnosis of IFPs, with only 10% of gastric lesions diagnosed correctly prior to resection [The differential diagnosis includes GIST, submucosal lipoma, and benign mesenchymal tumors such as schwannoma. Sometimes, differentiation is difficult, especially between IFPs and GISTs. Histologically, IFPs are typically characterized by vascular and fibroblastic proliferation with extensive eosinophilic infiltration , but theImmunohistochemistry plays also an important role in tumor classification and can confirm a definite diagnosis. Both tumors are usually positive for CD34 and vimentin, but only GISTs are positive for CD117 [Bearing in mind that IFPs are benign tumors, some authors used submucosal dissection for the treatment of small submucosal tumors, in the case of accessible lesions , 13. NevIn summary, IFPs can cause major pathology, especially chronic episodes of abdominal pain, vomiting, and anemia, mimicking other malignant or benign tumors or other gastrointestinal processes. Patients require emergency hospitalization, and only total excision of the tumor relieves from the symptoms and brings about a definite treatment.


Spontaneous pseudoaneurysms are uncommon vascular lesions in children. A seven-month-old boy presented for management of a painless, pulsatile mass of the volar forearm identified as a pseudoaneurysm of the radial artery on imaging, definitively treated with surgical excision. Histology was concerning for fibromuscular dysplasia, without additional lesions on whole-body imaging. Aneurysms are uncommon vascular lesions in the paediatric population. Defined as expansion of the vascular contour beyond its expected boundaries, they typically present as expanding pulsatile masses, occasionally causing pain and/or compression of adjacent structures. They are categorised into true aneurysms or pseudoaneurysms based on the constituents of the aneurysmal wall. True aneurysms are expansions involving all three vascular layers and are typically associated with connective tissue disease, trauma, or arterial infection . PseudoaHerein, we present a rare case of a seven-month-old boy with a spontaneous pseudoaneurysm of the radial artery and severe idiopathic medial hypoplasia, most consistent with fibromuscular dysplasia, definitively treated with surgical excision.A seven-month-old boy was referred for evaluation of a painless mass of the left wrist. His parents noticed a soft tissue mass 4–5 mm in diameter four months earlier with progressive enlargement. He had a benign birth history and no history of trauma, vascular access, or inherited vascular, collagen, or rheumatologic disorders.On examination, the patient had a 1 cm bluish, non-tender, pulsatile mass over the left radial artery . A DopplIntraoperatively, the arterial lesion was noted to be multi-lobular, focally bluish, and adhered to the flexor carpi radialis sheath, with the volar carpal branch of the radial artery exiting the mass. . The radOn histopathology, the specimen exhibited medial attenuation with large areas of complete media loss, consistent with pseudoaneurysm . Also noGiven the abnormal pathology and young presentation age, the patient underwent a genetics workup to evaluate for possible connective tissue disorders. He was noted to have a large body habitus and hyperelastic skin, concerning for EDS. MRA exams of the carotids, brain, chest, abdomen, and pelvis, recommended by vascular surgery at the age of thirteen months to assess for any further large/medium vessel lesions, were unremarkable. A cardiovascular genetics workup of sixteen genes associated with EDS, Marfan, and familial thoracic aortic aneurysm and dissection (FTAAD) found no pathogenic variants.At three years postoperatively, the patient used both hands symmetrically. There was no clinical evidence of growth arrest or cold intolerance. Ongoing monitoring for additional vascular abnormalities is planned.Pseudoaneurysm is an exceedingly rare diagnosis in children and is typically the result of traumatic vascular access, a history of which was present in both previously reported infantile brachial artery pseudoaneurysms ,5. No stFibromuscular dysplasia (FMD) is an occlusive disease of medium-sized arteries characterised by medial fibroplasia, disruption of the elastic membrane, and formation of saccular aneurysms, classically in a “string of beads” pattern . It is bCOL3A1 results in decreased or absent production of type III collagen, which is vital for vessel wall integrity and platelet plug formation. Patients bruise easily, and pseudoaneurysms of the subclavian, axillary, radial arteries may occur after minor trauma or angiography. Spontaneous ruptures of the aorta, major visceral arteries, and peripheral arteries in this population have also been reported [Ehlers-Danlos syndrome is a group of inherited connective tissue disorders presenting with problems related to collagen synthesis and processing. Classically, patients have hyperelastic skin, joint hypermobility, multiple ecchymoses, and subcutaneous pseudotumors . Six typreported . Surgeryreported . Marfan reported . Loeys-Dreported .In summary, we presented a rare case of a 7-month-old boy with a spontaneous radial artery pseudoaneurysm and severe idiopathic medial hypoplasia, most consistent with fibromuscular dysplasia, treated definitively with surgical excision of the lesion. Angiographic workup demonstrated no additional lesions, and genetic analysis did not provide a definitive diagnosis. No medium-term sequelae have been encountered, and the patient has continued to have full use of the operative extremity. Monitoring for additional vascular abnormalities is ongoing, given the theoretical risk of early-onset stroke.


A 33-year-old Asian male presented with spontaneous nosebleeds and olfactory sense problems for the past several years. CT scan and MRI demonstrated a large soft tissue mass in the nasal cavity and paranasal sinus with avid and homogeneous contrast enhancement, focal osseous destruction and a non-enhancing cyst at the intracranial tumour–brain margin. After complete endonasal resection, histopathological examination revealed a paraganglioma. This case highlights the non-specific imaging features of a rare paraganglioma of the anterior skull base and the differential diagnosis from both radiological and pathological perspective. A 33-year-old Asian male presented to the ENT clinic with complaints of spontaneous nosebleeds for the past 6 months. Furthermore, the patient also had been suffering from significant olfactory problems for more than 2 years but was reluctant to seek medical advice or any investigations for this. When asked, the patient complained of mild headaches in the anterior part of the head. He had normal vision and no hearing loss. Past medical history included kidney stones, a car accident 7 years ago and bilateral carpal tunnel syndrome, which required surgery on both sides. He had no allergies and used no medication. No tobacco, alcohol or drugs abuse. No occupational high-risk contact with carcinogens was reported. On neurological examination, he appeared a bright and oriented patient with absence of olfactory sense, intact vision, no hemianopia, normal motor function and reflexes, and normal global sensitivity. On clinical examination, a mass in the nasal cavity was suspected. Laboratory results were normal. CT and MRI demonstrated a large soft tissue mass in the nasal cavity.Non-enhanced CT imaging of the sinus showed a homogeneous soft tissue mass in the left nasal cavity and ethmoid with extension into the left frontal sinus. There were no focal dense areas suggestive of haemorrhage or calcifications. Slight mass effect on the left orbit and focal erosive bone changes of the orbital part of the left frontal bone, the superior orbital margin and glabella were seen .T1 signal intensity was isointense to muscle  diagnoses and metastatic disease in this article, but focus on primary tumours of the sinonasal cavity. In this case, owing to specific imaging characteristics, the main differential diagnosis was esthesioneuroblastoma , followed by squamous cell carcinoma (SCC) and adenocarcinoma, although our patient did not have specific high-risk factors for carcinoma (smoking).The differential diagnosis of enhancing nasal tumours with high 2 ENB may cross the midline through the nasal septum or extend into the orbits.ENB is a relatively rare, slow-growing, malignant tumour arising from the olfactory neuroepithelium and can extend into the lower anterior cranial fossa. The lesion is typically midline, centred around the cribriform plate, shows avid contrast enhancement and may variably appear heterogeneous on short tau inversion-recovery-weighted MRI.3 ENB typically can have microcysts.Both ENB and paraganglioma show homogeneous enhancement and can have a dumbbell shape, with ENB showing a typical waist at the cribriform plate. Furthermore, both show bone remodelling and erosion owing to expansive growth and finally, while ENB is characterized by its peritumoral cysts at the intracranial brain–tumour margin, paraganglioma can also have cystic parts at this location.2 It has a predilection for the maxillary antrum and is known for its aggressive behaviour and appearance, with heterogeneous enhancement, osseous destruction and often invasive growth into the orbits and pterygopalatine fossa, and early-stage lymph node metastases.3 On MRI, SCC shows intermediate T1 signal intensity and hypointense T2 signal compared with fluid. It demonstrates variable enhancement, less than the normal mucosa of the paranasal sinuses.3 The second most frequent is adenocarcinoma, which is more common in Asian individuals, favours ethmoid origin with nasal involvement and shows homogeneous contrast enhancement.1 However, both SCC and adenocarcinoma do not enhance to the same degree as ENB and paraganglioma. Poorly differentiated carcinoma cannot be excluded on MRI or CT scan, but is more common in older patients and originates mostly from the ethmoid sinus and superior nasal cavity. Imaging shows a heterogeneous soft tissue mass with aggressive features.1Of all the nasal carcinomas, SCC is the most frequent.3 On imaging, an inhomogeneous soft tissue mass is seen with non-specific features such as bone erosion, necrosis and early stage intracranial growth.2 Myeloid or granulocytic sarcoma, also called chloroma, is extremely rare and has a typically high T1 weighted imaging signal.2 Less likely diagnoses are melanoma, classically with high T1 and low T2 signal owing to melanin, and lymphoma, with a dense appearance on non-enhanced CT and low T2 signal owing to high cellularity. Therefore, we will also not discuss other small blue cell tumours here, such as Ewing sarcoma or primitive neuroectodermal tumour. Metastasis, plasmacytoma and malignant fibrous histiocytoma are all malignant tumours with a primary osseous origin.3This list of enhancing nasal tumours should be completed by mentioning sarcomas. Head and neck rhabdomyosarcoma originates most commonly in the orbits and nasopharynx and almost exclusively in children, with 70% of patients aged < 12 years, and only 12% involving the sinonasal cavities.T2 signal in the sinonasal cavity comprises inverted papilloma; peripheral nerve sheath tumours such as schwannoma and neurofibroma ; highly vascular lesions such as haemangioma; juvenile angiofibroma and haemangiopericytoma, with the latter having malignant potential; and benign neuroendocrine tumours such as paraganglioma.1The group of benign enhancing tumours with high 4 Both poorly differentiated carcinomas and melanomas are negative for neuroendocrine markers. Poorly differentiated carcinomas of the sinonasal tract are more aggressive, and thus show (higher) mitotic activity, occasional necrosis, marked nuclear pleomorphism and an infiltrative growth pattern. Melanomas are diffusely positive for S100.5 The chief cells of both ENB and paraganglioma show expression for neuroendocrine markers  and a lining of flattened S100-positive sustentacular cells.5On histopathological examination, the differential diagnosis is ENB, malignant melanoma and poorly differentiated carcinoma.5 On the other hand, ENB is known for (pseudo-)rosette formation and moreover, its abundant neurofibrillary background for which a neurofilament immunostain can be used. Its nuclear characteristics are fine chromatin and no or inconspicuous nucleoli.4However, paragangliomas can be distinguished by the bland appearance of their uniform polygonal chief cells arranged in well-demarcated nests  and sheets, and a background of eosinophilic granular cytoplasm. The chief cells contain round nuclei that vary in size with clumped chromatin or a prominent nucleolus, and a moderate-to-abundant amount of eosinophilic granular cytoplasm. Paragangliomas are not mitotically active, whereas ENB has a high k67 index rate.2 and 0.6% of all tumours in the head and neck region, with the four most common locations of occurrence being the carotid bifurcation, the jugular foramen, the vagus nerve and the middle ear, also called glomus caroticum, glomus jugulare, glomus vagale, and glomus tympanicum or glomus jugulotympanicum, respectively.6 Among other locations are the larynx, thyroid, nasopharynx, orbit, tongue and the paranasal sinus.Paragangliomas  are tumours of the paraganglia, defined as chains of tissue originating from the extra-adrenal neuroendocrine system. According to the World Health Organization, they account for less than 2% of all soft tissue tumours8 The exact origin is mostly the ethmoid sinus, followed by the lateral nasal wall and middle turbinate.6 Because of its slow growing and expansive behaviour, patients present at an older age and late in the course of the disease with nasal obstruction, epistaxis, facial swelling, pain and loss of olfaction. Most patients are between 40 and 60 years old, with a slight female predilection.6 Cases of paediatric paragangliomas suggest a genetic predisposition. Currently, we discriminate between isolated paragangliomas (75%) and hereditary paragangliomas (25%) which are often multiple, for instance, in multiple endocrine neoplasia syndrome type 2A and 2B. The latter more often occur bilaterally (10%). Screening for multiple germline mutations related to familiar head and neck paragangliomas can be performed, of which succinate dehydrogenase complex subunits B and D are the most important for predicting a malignant nature.10 While all paragangliomas contain neurosecretory granules, only in 1–3% of cases is the secretion of hormones such as catecholamines abundant enough to cause symptoms in the same way as pheochromocytomas (intramedullary paragangliomas), such as by hypertension and can lead to pertinent laboratory abnormalities.10Paragangliomas of the sinonasal tract are extremely rare, with less than 40 case reports described.T2 sequence, and avid and homogeneous contrast enhancement on both CT scan and MRI. The classical paraganglioma has a “salt and pepper” appearance on both T1 and T2 weighted images, which is of high diagnostic value when seen; the salt-like areas are high signal areas secondary to subacute haemorrhage, whereas the pepper-like areas are low signal intensity flow voids or vascular channels.8 A similar appearance may be seen on T2 sequences or post-contrast T1 sequences in patients with juvenile nasopharyngeal angiofibroma.3 Owing to slow growth, adjacent bone erosion and remodelling occur frequently.8 Larger masses can have degenerated cystic parts, not to be mistaken for necrosis. On angiography, a prolonged tumour blush is seen owing to hypervascularity. Indium-111 octreotide is used for nuclear imaging of paragangliomas.6Paragangliomas are vascular, expansive and sometimes destructive tumours. They have a lobulated and sometimes dumbbell-shaped appearance, show a slightly hyperintense signal on When there is clinical suspicion of a mass in the paranasal sinus, diagnostic work-up will routinely include at least a CT scan and MRI of the head and neck to determine the skull base and intracranial extent and unexpected multiple/bilateral paragangliomas or metastases. Thoracic and abdominal CT scans are performed on indication, also dependent on genetic mutation analysis and risk factors.3 CT imaging can also show calcifications.2 We suggest non-enhanced CT scan, with optional contrast-enhanced series.CT scan and MRI complement each other; CT scan of the sinus and/or brain is superior to MRI for bone evaluation; benign, expansive, slow-growing tumours that cause bone remodelling and erosion can be differentiated from lytic, aggressive, malignant behaving tumours.3 We suggest T1 weighted MRI with and/or without fat suppression, T2 and T1 weighted image with fat suppression and contrast administration, preferably in three-dimensional reconstructions, and optional susceptibility weighted imaging for (micro-)haemorrhage. Diffusion-weighted imaging and dynamic contrast-enhanced MRI may be of additional value.11MRI excels in demonstrating soft tissues and features such as high or low cellularity, central necrosis or (micro-)cysts, and vascular channels or haemorrhage. Moreover, MRI displays the exact location, size and possible extension into the pterygopalatine fossa, middle cranial fossa, orbits and brain. These features have an impact on diagnostic considerations and consequent surgical or therapeutic planning.12Oncologic guidelines and treatment algorithms of head and neck paragangliomas state that pre-operative fine-needle aspiration biopsy is optional. This can be performed safely by the ENT surgeon to establish a diagnosis. If surgery is contemplated, angiography is indicated to evaluate tumour blood supply and bilateral cerebral blood supply and possible vessel invasion.13 Some authors describe the usefulness of radiotherapy. Chemotherapy thus far plays no role in the therapy of paragangliomas.12Resection is the treatment of choice, often performed by both ENT surgeons and neurosurgeons with an endoscopic endonasal approach. The objective is to obtain disease-free resection margins, which is challenging since paragangliomas grow around normal vital structures. There is a preference for pre-operative embolization in tumours larger than 3 cm in order to reduce the vascularity and size of the tumour, leading to a smaller amount of peroperative blood loss.13 Prognosis is partly related to the location of origin; the skull base region has therefore a less favourable outcome since radical resection is more difficult to perform.6 Chances for malignant paraganglioma increase with a mutation in the succinate dehydrogenase (SDHB) gene.9 When malignant, sinonasal paragangliomas show aggressive behaviour with rapid local growth, vascular invasion and metastases to brain, lung, skin, bone and regional lymph nodes,10 especially in recurrent tumours. Recurrence rate in the head and neck region is about 10% and malignant transformation in a recurrent tumour is not infrequent (2–13%);8 cases have been described of malignant recurrence after 13 years of follow-up.10 Hereditary paragangliomas are more often bilateral (10%) and multiple, so screening and follow-up of other locations in these patients is also necessary. Thus far, no consensus has been reached about the duration of follow-up and the imaging of choice. Nuclear imaging might play an important role in the search for local recurrence and (lymph node) metastases.10The majority (97%) of paranasal paragangliomas are benign.The broad radiological differential diagnosis of enhancing (para-)nasal tumours makes it difficult to diagnose the extremely rare phenomenon of benign paraganglioma of anterior skull base, which shares most features with malignant ENB. Histopathology and immunohistochemistry lead to the final diagnosis and appropriate treatment.Benign tumours can behave aggressively on imaging.Imaging features of enhancing tumours of the sinonasal tract are often non-specific. There is a broad radiological differential diagnosis of both benign and malignant tumours.Histopathology plays a key role in the final diagnosis.Special appreciation goes to the faculty of Pathology of the Academic Centre of Amsterdam for technical, scientific and mental support for the admission of this case to the American Institute for Radiologic Pathology and publication of this manuscript.Informed consent to publish images and data was obtained and is held on record.


Soft tissue tumors involving the hand are common and most often benign. It is important to know the spectrum of soft tissue tumors of the hand and understand the typical as well as atypical imaging features are seen on different imaging modalities. The imaging features are largely determined by the tumor histopathology; thus, the basic idea about the tumor histopathology will always be useful. This article intends to focus on a comprehensive approach including demographics, clinical presentation, and imaging findings required to diagnose the tumor definitely or narrow the differentials. This article discusses common soft tissue tumor mimics of the hand as well, however, excludes the bone tumors for the sake of brevity. Another interesting fact is that 95% of hand tumors without skin involvement are benign. Most of the hand tumors present early, given the superficial location and thus readily visible and palpable. Thus, for these reasons, most of the hand tumors have a good prognosis. Malignant soft tissue tumors of the hand are rare and represent only 2% of all hand lesions.Embryologically, mesodermal mesenchyme differentiates into different soft tissue structures such as muscle, tendon, synovial sheath, skin, blood vessels, and nerves. Thus, hand tumor may comprise these soft tissue structures. Although both hands represent a total of only 2% of total body surface areaIn the increasingly imaging-reliant clinical practice, it is not uncommon for the radiologists to evaluate soft tissue hand tumors. This article provides an overview of the classification of common soft tissue hand tumors and highlights the important, useful imaging features of these tumors . By corroborating clinical history, lesion location, radiograph appearance, US finding, and MRI characteristics, it is possible to determine the diagnosis in subset of lesions, but other lesions will need workup with biopsy to exclude malignancy.A plain radiograph is the initial imaging ordered to evaluate the soft tissue tumor. Although it is not able to demonstrate the soft tissue tumor itself in the majority of cases, important information about the tumors can be occasionally obtained, for example, phleboliths in hemangioma, distal phalanx remodeling in epidermoid inclusion cyst. Ultrasound is less commonly used, but useful modality for soft tissue hand tumors. Given the superficial location, high-frequency transducer can be used to obtain high-resolution images of the tumor characteristics, for example, cystic versus solid tumor component, entering, and exiting nerve in relation to nerve sheath tumor. Color Doppler can provide important information about the vascularity to aid in the diagnosis as well. In cross-sectional imaging, magnetic resonance imaging (MRI) is frequently performed to characterize the soft tissue hand tumor. MRI signals are determined by the tissue composition; thus, it is helpful for radiologist to have understanding of the tumor histopathology as well.T1 coronal and axial, T2 sagittal and axial,T2 Fat saturated/Short TI Inversion Recovery (STIR) sequences on axial,Postcontrast images on axial and coronal plane,Three dimensional images, gradient recalled echo (GRE) sequences for vascular lesions,FOV: 12–16 cm; slice thickness 1.5–4 mm; Matrix: 512 × 256.The nomenclature of vascular anomalies in the literature is unclear often complicated and confusing. Based on clinical findings, cellular turnover and histology; vascular anomalies can be broadly classified into vascular neoplasms and vascular malformations. Hemangiomas are true neoplasms of children, while arteriovenous malformations consist of dysplastic vessels. Both are frequent in childhood and young age group. Initial rapid growth , then static phase , and ultimately slow involution is characteristic of hemangioma. About 50% involute by 5 years of age and about 70% involute by 7 years of age. Hemangioma does not recur. Apart from the vascular channels, the hemangioma may contain adipose tissue and phleboliths as well. On ultrasound, hemangioma appears moderately well defined and hypoechoic but can be heteroechoic due to internal adipose and calcium contents. Doppler may depict prominent vascular channels with the flow. Hemangioma is intensely hyperintense on T2 and hypointense on T1 unless have a hemorrhage or fatty replacement  It  and absence of internal vascularity.An epidermoid cyst is a differential, but to the contrary, epidermoid shows internal anechoic cysts, linear hyperechoic strands, posterior acoustic enhancement, laminated concentric ring “target” pattern, pseudotestis appearance, Dense fibrofatty tissues infiltrate the endoneurium, perineurium, and epineurium but nerve fascicles themselves remain intact. Macrodactyly is seen in 2/3rd cases. Involvement of median nerve frequently causes carpal tunnel syndrome. The accepted treatment is carpal tunnel release by surgically excising the flexor retinaculum. Ultrasound shows cable-like appearance with alternating hyperechoic (due to fibrofatty tissue) and hypoechoic  bands. T1-weighted MRI image shows typical “coaxial cable” on the axial plane and “spaghetti appearance” in the sagittal plane due to alternating intermediate neural tissue and hyperintense fatty tissue The differential is an intraneural lipoma, which is an encapsulated tumor that displaces the neural tissues eccentrically but does not infiltrate. The distinction is important since intraneural lipoma can be excised surgically given its non-infiltrative nature, but fibrolipomatous hamartoma cannot be excised surgically given its infiltrative nature. The age at presentation is different as well since intraneural lipoma occurs in the fourth or fifth decades. Histology reveals a nonencapsulated disorganized collection of axons, Schwann cells, endoneurial/perineurial cells, and fibroblasts in scar tissue. On the US, it is seen as fusiform hypoechoic nodule in ultrasound, with entering/exiting nerve evident only if the neuroma is big enough. On MRI, it is seen as a T2 hyperintense nerve terminating in a baseball-shaped mass resembling a balloon on a string or a green onion appearance [Traumatic neuroma is the non-neoplastic proliferation of the injured or transected  proximal segment of the nerve. Traumatic neuromas are of two types: (a) Spindle neuroma: Swelling around an intact nerve after chronic irritation and (b) stump neuroma: Swelling at the end of a partially or completely transected nerve. They arise about 1–12 months post nerve injury. The characteristic symptom is intense neuralgia; Tinel’s sign is positive. A mass might be palpable if large enough. A neuroma is more common in lower limb and head/neck region, rather than the upper limb.pearance . Traumat It is well encapsulated and does not intertwine with the nerve fascicles; thus, complete surgical excision is easy without injuring the corresponding nerve . The US shows well defined hypoechoic mass, with cystic degeneration and with long axis along the direction of the nerve. Color Doppler shows internal vascularity. MR shows T1 low-to-intermediate signal and T2 high signal with post-contrast homogeneous avid enhancement. The “split-fat sign” is the peripheral rim of perineural fat compressed by the tumor [ These signs are very useful to make the diagnosis of a nerve sheath tumor. Differentiation from neurofibroma is usually not possible with imaging. Cystic schwannoma might simulate a ganglion – entry and exit nerve roots can be seen with cystic schwannoma, which itself is a rare entity. On MR, it appears usually T1 hypointense (can be variable depending on the protein content) and T2 hyperintense. On post-contrast images, enhancement of the thin walls and septations is noted.Peripheral nerve sheath tumors of hand comprise schwannoma and neurofibroma. Schwannoma is a benign neoplasm of Schwann cells. Thus, it is often seen along the course of the nerve. It commonly presents in middle-aged adults without symptoms or with pain or paresthesia. A positive Tinel’s sign can be elicited, i.e., percussion to the mass will result in tingling and pain on the nerve distribution.he tumor . The “fa The patient presents at 3rd-5th decades in life with fingertip intense pain, extreme tenderness to minimal pressure and temperature sensitivity. Non-specific deformity and discoloration of the overlying nail are present, which is seen in any nail bed tumor due to very tight subungual space. The US shows well-defined small hypoechoic nodule beneath the nail bed, with adjacent distal phalangeal bony erosion. Doppler shows prominent internal vascularity, which is an important finding. MRI shows T1 low-to-intermediate, T2 high signal, and post-contrast homogenous intense enhancement. The avid enhancement is explained by the prominent vascular spaces interspersed with the stroma containing glomus cells [Glomus tumor is hamartoma of glomus body. Glomus body is a special type of arteriovenous anastomosis in the dermis for thermoregulation. Glomus bodies are highly concentrated in digits, palms, and soles; thus, reflecting the predominant distribution of glomus tumor in these areas. Up to 75% of glomus tumors occur in hand; up to 65% occur at fingertips, predominantly at subungual space.us cells . The rol Moreover, extreme pain and tenderness in glomus tumor also differentiates it from other differentials. Epidermal inclusion cyst can be differentiated from glomus tumor by the lack of internal vascularity but the only the presence of peripheral rim enhancement.Differentials include hemangioma and epidermal inclusion cyst. Imaging features of hemangioma are similar, however presence of a fat component, phlebolith, calcification, and flow voids favor hemangioma over glomus tumor. The common locations are the hands (85% in fingers) or feet. Plain radiograph can show cortical erosions on the underlying bone ~ 20%. Periosteal reaction and calcification are uncommon. Ultrasound shows homogenous hypoechoic lesion with internal vascularity. With dynamic maneuver, it does not move with flexion or extension of the adjacent tendon. On MR, it shows T1 low- and T2 low-to-intermediate signal [ FTS is a differential, which does not show cortical erosion and “blooming.” Gouty tophi also appear T1 and T2 low, but tophi are usually multiple and intra-articular instead.Latest the WHO classification (2013) has replaced the term giant cell tumor of tendon sheath (GCTTS), pigmented villonodular tumor of the tendon sheath (PVNSTS), or extra-articular PVNSTS with TSGCT. It presents as a lobulated painless soft tissue mass immediately adjacent to tendon sheath. Typical age group is 30–50 years. It is almost always solitary; multifocal involvement is extremely rare with only five cases reported.e signal . It show,32 It is intermediate to high-grade malignancy with high metastatic potential. Irrespective of the nomenclature, neither does it arise from the synovium nor does it express synovial markers. It can occur at any age and in any location. The majority (80–95%) occurs in the extremities; lower extremity is most often affected around the knee, whereas 16%–25% occur in the upper limb. Soft tissue mass near but not in a joint in a patient 15–40 years of age particularly if calcification is present, synovial sarcoma should be considered a possibility. Nonspecific calcification is seen in 1/3rd of cases. It is frequently mistaken as benign pathology due to small size (<5 cm), slow indolent growth , calcification, and well-defined lobulated outline. Imaging is not pathognomonic, but suggestive of the diagnosis. The US shows benign appearing hypoechoic, complex lesion with internal vascularity in solid component. Computed tomography is useful to show calcification and bone involvement. MRI shows multilobulated mass with marked heterogeneity with hemorrhage, fluid-fluid levels, and septa creating the “bowl of grapes” appearance. The marked heterogeneity aka “triple sign” on T2-weighted MR images is due to the result of the mixture of solid cellular elements, hemorrhage or necrosis, and calcified or fibrotic collagenized regions [Synovial sarcoma is a relatively common tumor, representing 5–10% of all soft tissue sarcoma. regions . PredomiSquamous cell carcinoma occurs in the elderly age group. Diagnosis is usually suspected clinically and confirmed with a skin biopsy. Imaging features are variable, however heterogeneous signal due to fascial edema, hemorrhage and necrosis, irregular margins, and lobulation suggest the diagnosis of malignant etiology. MR imaging of the tumor is done for local staging, which shows infiltrative growth pattern, low to intermediate signal on T1W images and heterogeneously hyperintense on T2W images. Tumor shows heterogeneous and variable enhancement. An important diagnostic clue is irregular and infiltrative mass epicentered to cutaneous tissue. Ganglion may form due to chronic irritation and degeneration of tendon sheath or may arise from a joint. Thus, it is located near the tendon sheath or joint. Most commonly it occurs in dorsum of the wrist from the scapholunate joint. It is most common in young adults and 3 times more common in females. The fluid is thick and mucoid. Since it is superficial and fluid filled, it can be readily imaged with ultrasound. Ultrasound can show hypoechoic fluid filled the smooth structure with thin septations; however, the connection with the joint of origin is difficult to image. It may be multilocular or variably echogenic depending on the protein content of the fluid. Color Doppler will show the absence of internal vascularity, which will differentiate from solid lesions as nerve sheath tumor and vascular anomalies. On MRI cyst are typically hyperintense on T1- weighted image due to proteinaceous contents and hyperintense on T2-weighted image [Ganglion represents the most common cause of mass in the wrist area.ed image . MRI is  The most commonly affected age group is 20–40 years. It is often misdiagnosed initially as sarcoma due to its rapid growth within month duration. Thus, incisional/excisional biopsy is required for the diagnosis; fine-needle aspiration is not adequate to make the diagnosis. Histopathologically, it contains abundant spindle-shaped myofibroblasts with typical mitotic figures, but without hyperchromasia and pleomorphism. Myxoid component predominates in the early lesion, but fibrous component predominates in the mature lesion. Imaging features are non-specific and depend on the internal content of fibrous, cellular, or myxoid components. The myxoid form is T1 isointense to hyperintense to skeletal muscle and T2 hyperintense to adipose tissue. Highly collagenous lesions have a hypointense signal on all MR images. Contrast enhancement is typically diffuse but may be peripheral in lesions with cystic changes or extracellular matrix [Nodular fasciitis is a benign rapid reactive self-limiting proliferation of myofibroblasts leading to fibromatosis. It usually involves a subcutaneous plane, but can also affect fascia or muscle. 46% of cases are seen in the upper extremity, particularly the volar aspect of the forearm. Hand involvement is rare 0–2% and hand involvement also has a history of hand trauma in 38.5% of cases.r matrix .The main differential is the sarcoma given the rapid growth and gross histopathology finding. Worrisome features suggestive of sarcoma over nodular fasciitis are age over 70 years, multiple lesions, lesion recurrence, perilesional tissue edema, or hemosiderin on MRI.Benign tumors of hand mostly have well-defined margins and tend to show homogenous signal on T2W sequences. Hemangioma and schwannoma show homogenous contrast enhancement. Fatty lesions like lipoma have hyperintense signal on both T1 and T2W sequences. Fibrous lesions like FTS are hypointense on all MRI pulse sequences. On the other hand, malignant tumors have irregular infiltrative margins with lobulation. Malignant tumors show heterogeneous signal and heterogeneous enhancement due to fascial edema, hemorrhage, and necrosis. However, few exceptions exist, for example, malignant sarcoma may show well-defined margins and may insinuate the fascial and intermuscular plane like lipoma. On the other hand, desmoplastic fibroma has irregular infiltrative margins simulating malignancy. Intermediate lesions such as neurofibroma, GCTTS, and glomus tumor may show bone scalloping. Tumor mimics like nodular fasciitis simulate malignancy due to imaging features and rapid growth .Knowledge of typical and atypical imaging features of hand tumors is important to radiology practice. However, imaging features need to be interpreted in the background of patient demographics and clinical presentation as well. Although MRI is undoubtedly important imaging modality for soft tissue hand tumors, other initially ordered imaging modalities as radiographs and ultrasound can also add valuable information about the lesions. However, in many cases, ultimately patient will need a biopsy for a definitive diagnosis to rule out the malignant lesions.


Gall bladder anomalies may be in the form of abnormalities in the shape, position, or number. It could be true duplication being completely separated or Y-shaped being united with single cystic duct.A 38-year-old lady presented with frequent attacks of right hypochondrial pain for the last 4 months. Ultrasound of the abdomen showed distended gall bladder with 1.3 cm gall bladder polyp at the region of the fundus. Decision done for laparoscopic cholecystectomy. During surgery a duplicated gall bladder found with single cystic duct. Successful surgery done and the gall bladder sent for the histopathological examination which showed a benign gall bladder polyp. There were no post-operative complications and the patient discharged on the third days.Duplicated gall bladder may be diagnosed with ultrasound or magnetic resonance cholangiopancreatography (MRCP) which is the investigation of choice however most cases diagnosed intraoperatively. It may be associated with other biliary anomalies. In some occasions a single gall bladder may be removed during the first operation and the second may be missed which require another surgery. In asymptomatic individuals with duplicated gall bladder no specific treatment is required and role of surgery is controversial.duplicated gall bladder is a rare finding which may be completely asymptomatic. In symptomatic patients specially if associated with gall stones, surgery is required and the surgeon must be aware of any associated biliary anomalies. Gall bladder anomalies may be in the form of abnormalities in the shape, position, or cystic duct. They are usually discovered during surgery for gall stone disease or other surgeries involving the biliary system of the liver .Anomalies of the shape could be in the form of bilobed gall bladder in which there is a single cavity with a longitudinal septum inside and a single cystic duct, hourglass type in which a transverse septum is present, Phrygian cap in which a transverse septum is present but with smaller proximal cavity. Anomalies of the number had been reported being two in number in most cases or very rarely three, it could be true duplication being two completely separated gall bladders or Y-shaped being united with single cystic duct before joining the common hepatic duct .Duplication of the gallbladder is estimated to occur in about 1:4000 live births. Such anomaly may predispose to the development of gall stones due to impaired emptying of the gallbladder .The work in this case presentation has been reported in line with the SCARE criteria .2A 38-year-old lady presented with frequent attacks of right hypochondrial pain for the last 4 months, the pain was mainly at the night time and was associated with nausea, no vomiting, and no fever.The patient had no history of any medical diseases, and the past surgical history was negative.Ultrasound of the abdomen showed distended gall bladder with 1.3 cm gall bladder polyp at the region of the fundus.Advices given to the patient to reduce the fatty meals and antispasmodic medications prescribed with little improvement. Decision done for laparoscopic cholecystectomy. During surgery a duplicated gall bladder found with single cystic duct. Successful surgery done and the gall bladder sent for the histopathological examination which showed a benign gall bladder polyp , Fig. 3.There were no post-operative complications and the patient discharged on the third day.3The radiologists should be familiar with gall bladder duplication for the accurate diagnosis before surgery especially if is associated with gall stone disease. The condition can be diagnosed with ultrasound examination however magnetic resonance cholangiopancreatography (MRCP) is the investigation of choice to delineate the biliary anatomy and for the accurate preoperative plane ,6.Duplication of the gall bladder may be associated with duplication of cystic duct; the anatomy should be precisely visualized during surgery to avoid injuries to other structures .In some rare occasions a single gall bladder may be removed during the first operation and the second one may be missed which could be diagnosed after surgery by means of MRCP or ERCP. This may mandate the surgical removal of the other gallbladder .When the condition is diagnosed during surgery, intraoperative cholangiography may be required to detect any other associated biliary anomalies before proceeding with the surgical removal of the gallbladders. Sometimes the intraoperative findings may not be very clears especially if the two gall bladders are enclosed in a single peritoneal covering ,12.In most of the cases the operation is done with no complications although there may be some difficulties especially during dissection and delineating the anatomical structures which is very important to avoid iatrogenic injuries or missing the second one. Awareness about the presence of this condition before surgery is of utmost importance to prevent or decrease the rate of such complications .The clinical presentation of duplicated gall bladder is similar to other cases which is due to stones or inflammatory process presenting as acute or chronic cholecystitis. Most authors agree in the cases of asymptomatic duplicated gall bladder requires no specific treatment and role of surgery is controversial .The author has no conflicts of interest to declare.None.Ethical approval has been exempted by my institution for reporting this case.An informed consent is taken from the patient for publishing this case report.Dr Ayad Ahmad Mohammed contributed to the concept of reporting the case and the patient data recording.Drafting the work, design, and revision done by Dr Ayad Ahmad Mohammed and Dr Sardar Hassan Arif.Dr Ayad Ahmad Mohammed and Dr Ihsan Salih Hussein took the consent from the patient for publishing the case.Final approval of the work to be published was done by Dr Ayad Ahmad Mohammed, Dr Ihsan Salih Hussein and Dr Sardar Hassan Arif.This work is case report and there is no need of registration.Dr Ayad Ahmad Mohammed is guarantor for the work.Not commissioned, externally peer-reviewed.


Trigger finger is ten times less common than trigger thumb in infants and children and, unlike trigger thumb, may arise from a variety of underlying causes. To our knowledge, we describe the first case of pediatric trigger finger secondary to an extraskeletal chondroma.  We report the case of an 11-year-old girl presenting with a typical history of triggering of the fourth finger, in whom a nodule attached to the flexor digitorum superficialis was found; clinical, ultrasound, and operative findings are described. Histological analysis was diagnostic of extraskeletal chondroma, also known as chondroma of soft tissues.  This is a very uncommon benign cartilaginous tumor, mostly reported in patients aged 30 to 60 years , and presentation with trigger finger has been reported just once, in a 76-year-old man. This condition should be considered in the differential diagnosis of pediatric trigger finger. Trigger finger is ten times less common than trigger thumb in infants and children .Unlike trigger thumb, pediatric trigger finger may arise from a variety of underlying anatomic causes, including nodularity or thickening of the flexor digitorum superficialis (FDS) or flexor digitorum profundus (FDP) tendons, abnormal relationships between the FDS and FDP tendons, proximal FDS decussation, and constriction of the A1, A2, or A3 pulleys. More uncommon causes include intratendinous calcification, granulation tissue, cysts, and the association with mucopolysaccharide storage disorders (Hurler syndrome and Hunter syndrome) [To our knowledge, trigger finger secondary to an extraskeletal chondroma (EC) has never been reported in children.The aim of this work was to describe our experience of a trigger finger in an 11-year-old girl, which was found to be secondary to EC.An 11-year-old girl presented with a typical history of triggering of the fourth finger of her left hand which started six months before. The girl could move completely her finger, but in the position of flexion, locking of the digit occurred and passive unlocking caused discomfort.At physical examination, a nodule of about 5 mm was palpable at the site of triggering, just distally to the distal palmar crease in line with the fourth finger.Ultrasound examination  showed aSurgery for excisional biopsy and release of the triggering was performed under general anesthesia. A 1.5 cm transverse skin incision was performed at the distal palmar crease, just proximally to the A1 pulley area. Longitudinal incision of the A1 pulley revealed the nodule with a diameter of about 6 mm, attached to the tendon of the FDS. The nodule moved out of the A1 pulley as the digit was flexed and entered the pulley with difficulty as the digit was extended, causing catching and sudden release of the tendon. No relationship with the FDP or with the underlying metacarpal bone was found. The mass was excised from the tendon using a scalpel and referred for histopathological examination. The histological analysis Figures  and 3 waThe postoperative course was uneventful with rapid recovery of the complete range of motion. At the last follow-up, 27 months after surgery, magnetic resonance did not show recurrence and the patient did not report any episode of triggering after the operation.EC (or soft tissue chondroma) is a rare benign  cartilaginous tumor with uncertain aetiology  arising First described by Baumuller in 1883 , EC is aOur literature analysis of EC affecting the hand and upper extremity  revealedClinical appearance was typically characterized by swelling due to a palpable subcutaneous mass; the three cases within the carpal tunnel were associated with symptoms of carpal tunnel syndrome. Trigger finger secondary to EC, similar to what we have reported in an 11-year-old girl, was described only in a 76-year-old man . All casExtraskeletal chondroma is a rare benign tumor in the hand. Depending on where the EC is located, it can cause symptoms and mimic other conditions as described in our case . This co