Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient’s body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods  with the respective imaging findings. Acute abdominal and pelvic pain during and just after pregnancy poses unique diagnostic and therapeutic challenges, owing to a variety of multiple confounding factors related to gestation and puerperium.Physiologic leukocytosis in pregnant patients, for instance, and a significant overlap between symptoms that occur as part of a normal pregnancy and those due to underlying disease, make clinical assessment difficult .The enlarging uterus displaces the adjacent organs from their normal locations, limiting physical examination; therefore, the classic clinical semeiotic in acute pain is altered .A wide range of conditions that are associated with or unrelated to pregnancy may cause abdominopelvic pain, making differential diagnosis extensive. The delay in diagnosis and intervention may lead to poor outcomes for both the mother and the foetus.The puerperium period, which may take as long as 8 weeks from birth, is also burdened by a wide clinical spectrum of complications, significantly associated with the delivery method. A multimodality imaging approach is often required to clarify an indeterminate clinical scenario in pregnancy and puerperium, playing an important role in the assessment of complications and expediting diagnosis.Ultrasonography (US) is the first line of imaging investigation both during and following pregnancy, because of its availability, portability and lack of ionizing radiations. However many causes of acute abdominal pain are not readily diagnosed with US, especially in later stages of gestation . The draAcute appendicitis (AA) is the leading cause of acute abdominopelvic pain during pregnancy, occurring in about 0.07% of cases (1 in 1500 pregnancies), most often in the second trimester. It also represents the most common non-obstetric surgical emergency in pregnancy . DiagnosAccording to ACR Appropriateness Criteria, US with graded compression is the first imaging modality for pregnant patients with suspected AA, as it does not involve ionizing radiation . The diaA recent meta-analysis, including 1593 patients, showed a relatively low diagnostic accuracy of US for AA during pregnancy, with a sensitivity of 77% and a specificity of 75% . The senAs in non-pregnant patients, AA sonographically appears as a blind-ending, dilated (>6–7 mm in diameter), peristaltic, non-compressible and thick-walled (>2 mm) tubular structure arising from the cecum. Indirect features include fluid effusion in the right iliac fossa and periappendiceal fat stranding .Segev et al. showed that if the appendix is detectable and diagnostic criteria for AA are met, the positive predictive value of US is 94%. However, the negative predictive value is low (40%) . TherefoMagnetic resonance imaging is a valuable tool for diagnosing AA in pregnant women due to its lack of ionizing radiation when compared to CT with high sensitivity and specificity of 91.8% and 97.8%, respectively . FonsecaOne of the major advantages of MRI is its 100% negative predictive value for the diagnosis of AA in pregnancy . Rapp etThe MRI findings for AA mirror those of other modalities, including an enlarged appendix (diameter greater than 7 mm), with a thickened wall due to mural oedema (>2 mm), high signal intensity luminal contents on T2 weighted-images (T2WI) and periappendiceal fat stranding or free fluid ; the appIn DWI, the inflamed wall may exhibit restricted diffusion both in perforated and non-perforated cases . MRI maySurgical intervention is recommended in the first 24 h in pregnant patients after the diagnosis of AA to avoid complications, such as perforation.SBO is a common clinical entity that is extremely rare in pregnancy, with an incidence rate of 0.001–0.003%, carrying a significant risk to mother and foetus: Webster et al. reported a maternal mortality rate of 2% and a fetal loss of 17% . SBO in The diagnosis of IH is clinically challenging, and the challenge is exacerbated in pregnancy. The literature on the imaging of IH, specifically in pregnant women, is scarce. Krishna et al. evaluated the utility of MRI in the diagnosis of IH in pregnant women who had previously undergone Roux-en-Y Gastric Bypass (RYGB); the authors showed that the signs with the best interobserver agreement and diagnostic odds ratio were mesenteric swirl, SMV beaking, mesenteric vascular congestion and mesenteric edema.This study reported that MRI has a comparable specificity to CT (86–100%) and a lower sensitivity (75–88%), concluding that MRI might be a reasonable and safe alternative to CT . In contIBDs, including Crohn’s disease and ulcerative colitis, commonly affect women in the reproductive-aged population, with a peak incidence between 15 and 25 years. Most pregnancies in patients with quiescent IBD are uncomplicated. When IBD is exacerbated, it usually presents with fever, bloody diarrhoea and abdominal pain . IBD is MRI is the preferred modality to assess active IBD and its complications in pregnancy, with a sensitivity and specificity ranging from 88% to 98% and 78% to 100% . IBD-relPregnancy-related liver diseases (PLDs) represent the most frequent cause of liver dysfunction in pregnancy and affect up to 3% of pregnant women. When severe, these conditions are associated with significant morbidity and mortality for both the mother and the foetus .PLDs exhibit trimester-specific characteristics, whereas non-pregnancy-related liver diseases can occur at any time . The timPLDs include intrahepatic cholestasis of pregnancy (ICP), acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes and low platelets count (HELLP) syndrome. In addition, pre-eclampsia (PE) and hyperemesis gravidarum (HG) are frequently associated with liver abnormalities ,33.Transabdominal US and MRI can be safely performed in pregnant women to evaluate the liver. In doubtful cases, the use of computed tomography (CT) could be required, involving radiation exposure to the foetus.ICP, also known as obstetric cholestasis, is the most common pregnancy-specific liver disorder, with a reported incidence ranging from 0.2% to 2% . ICP is US is the method of choice; the liver usually shows a normal echotexture, but in the presence of biliary symptoms, US may be useful to rule out other causes of obstructive biliary tract pathology .Acute fatty liver of pregnancy (AFLP) is a rare and potentially fatal disorder for both the mother and the conceptus, resulting from the micro-vesicular fatty infiltration of hepatocytes, which can lead to liver failure .It usually occurs in the third trimester with an incidence of 1/7000 to 1/16,000 obstetric emergencies, or in the early post-partum period . The mosCurrently, the diagnosis and management of AFLP is based on clinical and laboratory findings alone in almost all patients. Hypoglycaemia is a poor prognostic sign. Imaging could show signs of fatty infiltration of the liver, although current diagnostic modalities have limited utility in the setting of AFLP. US of the liver may demonstrate a hyperechoic appearance of the hepatic parenchyma from fatty infiltration. MRI performed with T1 dual gradient-echo in-phase (IP) and out-of-phase (OOP) sequences can show a drop in liver signal intensity on the OOP images, suggestive of steatosis .HELLP syndrome is a variant of severe pre-eclampsia that occurs in 0.2–0.6% of all pregnancies and in up to 12% of patients with pre-eclampsia . This coIt can be classified into mild, moderate or severe depending on the alanine aminotransferase (ALT), lactate dehydrogenase (LDH) levels and platelet count, and as early (<34 weeks) or late (≥34 weeks) according to the gestational age at diagnosis or delivery .There is no specific symptom or sign that differentiates HEELP syndrome from pre-eclampsia. Right upper quadrant abdominal pain is the most common feature. Other vague symptoms include nausea, vomiting and headache. Diagnosis is mainly based on clinical presentation and laboratory findings ,39. In aHowever, diagnostic imaging should be recommended in patients with suspected HEELP syndrome, and who also report abdominal pain, to rule out life-threatening complications such as hepatic parenchymal hematoma or infarction, and hepatic rupture secondary to necrosis or haemorrhage ,41. US aSonographic findings are often nonspecific, including enlarged liver (predominantly the right lobe), peri-portal edema and free abdominal fluid. On US, hepatic hematoma can appear as a peripheral area, heterogeneously hypoechoic as well as isoechoic, relative to the uninvolved liver; the diagnosis has to be further confirmed by cross-sectional imaging . CT and Liver infarction can be undetectable through US or appear as peripheral geographic hypoechoic bands . MRI canThe development of hepatic capsular rupture is a rare but catastrophic event, occurring in less than 2% of patients with HELLP syndrome . PatientAcute cholecystitis (AC) is the second most common non-obstetric indication for surgery during pregnancy, often resulting from an impacted stone in the cystic duct. The prevalence of gallstones during pregnancy is higher than 12%, whereas symptomatic biliary disease is uncommon, occurring in 0.1–0.3% of patients .Pregnancy is a known risk factor for the development of gallbladder disease due to the increased levels of circulating estrogen and progesterone, which lead to cholestasis and supersaturation of bile with cholesterol . AC is tAs in the general population, a right upper quadrant US is the first imaging modality of choice when the clinical presentation is suggestive of biliary pathology . US typiIn a meta-analysis of 5859 patients with AC in the general population, the sensitivity and specificity of US has been reported at 81% and 80%, respectively; the author concluded that the diagnostic accuracy of US has a substantial margin of error, comparable to that of MRI .Although US usually provides the definitive diagnosis of AC, MRI should be employed as a second-line tool in equivocal cases for further assessment of the biliary tree and gallbladder, or to confirm clinal suspicion of complications . MR cholMRI findings of AC include hydropic distention, gallbladder wall thickening with edematous stratification and pericholecystic inflammatory changes; these features are best imaged on fluid-sensitive T2-weighted fat-suppressed sequences .MRCP offers an excellent depiction of the biliary system, gallbladder and pancreatic duct. Stones are shown as rounded or angular geometric filling defects, easily detectable on thin-cut sequences, against the hyperintense signal of the bile . MRI enaMoreover, MRI allows for the identification of any complications of AC. In gangrenous cholecystitis, MRI shows asymmetric thickening and irregularity of the gallbladder wall with increased signal intensity on T2WI; other signs of gangrenous cholecystitis, including ulceration, haemorrhage, necrosis or microabscesses in the gallbladder wall, are best depicted through MRI . The finClinical practice guidelines by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommend early surgical management with laparoscopic cholecystectomy for pregnant women with symptomatic gallbladder disease, regardless of trimester .Acute pancreatitis in pregnancy is a rare, usually self-limiting condition, estimated to occur in every 1/1000 to 1/5000 cases, often in the third trimester . MaternaUS of the right upper quadrant is aimed to confirm or rule out biliary etiology; it is a safe, reliable and cost-effective method but its use is limited by the patient’s body habitus, especially during the third trimester of gestation, and/or by the overlap of bowel gas . If US iMRI demonstrates pancreatic enlargement and oedema, with reduced intensity on T1-weighted images and increased intensity on T2-weighted images .On DWI, acute early pancreatitis shows restricted diffusion and lower ADC values than the spared parenchyma . In sevePhysiologic hydronephrosis is the most significant change in the urinary tract during pregnancy, occurring in up to 90% of patients, especially in primigravidas. It is an asymptomatic condition, secondary to increased progesterone, which causes ureteral smooth muscle relaxation, and to the compression of the ureter between the gravid uterus and the ileopsoas muscle . PhysiolRenal colic represents severe pain associated with obstructive hydronephrosis, most often caused by a kidney stone; it is the leading non-obstetric cause of abdominal pain and subsequent hospital admission during pregnancy . The incMaternal physiologic changes, such as the aforementioned physiologic hydronephrosis, make it challenging for the urologist to rely on traditional clinical signs and symptoms of urolithiasis for diagnosis, complicated by the concern of avoiding exposing the conceptus to radiation from CT.Ureteral obstruction may lead to significant maternal morbidity, including pyonephrosis, urosepsis, preterm labor, cesarean delivery, hypertensive disorders and gestational diabetes; these potential complications make timely and accurate diagnosis crucial so that proper management can be initiated for the health of the pregnant patient and the foetus .Ultrasonography (US) represents the primary radiological investigation of choice to evaluate for suspected urolithiasis in pregnancy, due to its lack of ionizing radiation, low cost and availability. However, several limitations, such as the patient’s body habitus, the overlap of bowel gas and dependence on the operator, reduce the diagnostic accuracy of this method; the performance in terms of sensitivity for urolithiasis is quite low (11–24%), especially in cases of middle ureteric stone . MoreoveDoppler ultrasound findings, such as differences in the resistive index (RI), the absence of ureteral jets and twinkling artefact, can help to increase diagnostic accuracy in detecting ureteral stones. RI does not appear to be affected by gestational hydronephrosis, providing an indirect estimate of the renal perfusion that can be reduced in the setting of obstructive uropathy, due to back pressure on the collecting system; an elevated intrarenal RI (≥0.70) and a mean delta RI value  falling in the range of 0.04–0.08, between the symptomatic kidney and the contralateral one, raise suspicion of an obstructive process .The absence of a “ureteral jet”  on the symptomatic side may increase sensitivity and specificity to 100% and 91%, respectively. However, patients should be scanned in the contralateral decubitus position to decrease false-positive results .Magnetic resonance urography (MRU) is a non-invasive and non-operator-dependent method, representing the second-line test for suspected urolithiasis in pregnancy, when US is equivocal .The use of heavily T2-weighted or water-weighted images with thick slabs is helpful in depicting the urinary system, enabling differential diagnosis between physiological and obstructive hydronephrosis ,79.MRU findings in physiological dilatation include a lack of visible filling defects and a collapsed ureter below the pelvic brim; there is a characteristic smooth tapering of the middle third of the ureter, due to the mass effect between the gravid uterus and adjacent retroperitoneal musculature ,74.Urolithiasis produces a different MR pattern; an acutely obstructed kidney is asymmetrically enlarged and edematous, showing an increased T2-weighted signal intensity of the parenchyma. The MR urography appearance of a “double kink sign”, with constriction at the pelvic brim and the vescicoureteral junction with a standing column of urine in the pelvic ureter, suggests an obstructing distal ureteral stone .Other features that are indicative of pathological hydronephrosis include an “unusual” site of obstruction, an abrupt ending of the ureter (rather than smooth tapering at the level of the pelvic brim) and perirenal or periureteral fluid (reflecting lymphatic distension and fluid leakage from the obstructed kidney) ,75.A filling defect within the lower ureter is a direct sign of obstruction, although the sensitivity of MRI for stone detection may be limited by calculus size; the use of thin slice 3 mm), high-resolution T2 fast spin echo (FSE) sequences improves the accuracy in identifying small stones  mm, high,79.The impaired egress of urine (urinary stasis), due to stones, increases the risk of complications, such as acute pyelonephritis, reported in 1% of pregnancies ; in thesIn patients who develop renal abscesses, T2-weighted and DW images respectively show a focal, more hyperintense signal and restricted diffusion, compared to the rest of the parenchyma involved in nephritis ,54 Figu.MRU has several drawbacks (when compared with non-contrast CT) because of its lower spatial resolution, prolonged imaging times, limited availability, poor sensitivity to detect small stones and interference with metal objects . FurtherThe usefulness and benefit of low-dose CT for evaluating suspected urolithiasis has been confirmed in the non-gravid population; CT showed superior sensitivity and specificity (98% for both) to other diagnostic techniques in localizing urinary tract stones, providing information for causes of non-urologic flank pain. However, diagnostic modalities that use ionizing radiation should be avoided in pregnant patients, owing to risks to the foetus. Low-dose CT should, therefore, be considered in unresolved cases as a last-line test alternative to MRI, only during the second and third trimesters, when the foetus is relatively less radiosensitive compared to the first trimester ,83.Overall, recent instances in the literature reported that the positive predictive value of CT, MRI and US is 95.8%, 80% and 77%, respectively, for the detection of urolithiasis during pregnancy ,84.Ovarian torsion (OT) is the fifth most common gynecological surgical emergency, with a reported incidence of 2–3%. However, during pregnancy it is a rare event, occurring in 1 in 800 patients, more commonly in the late first to early second trimesters, when the uterus is rapidly enlarging ,86. SomeThe torsion may occur in the normal ovary, when it twists on its ligamentous supports, but it is usually secondary to a preexisting adnexal mass, including hemorrhagic cysts, simple cysts, endometriomas and benign tumours . Clinical features are non-specific, with intermittent abdominal pain, nausea and vomiting; most patients are symptomatic (94–100%). Early diagnosis and surgery are necessary to avoid adnexal necrosis, and preserve ovarian function in the patient .US combined with color Doppler imaging is usually the first imaging tool for the diagnosis of OT: it should be suspected in any pregnant patient with an adnexal mass and lower abdominal pain. A unilateral enlarged ovary (>5 cm) with or without a pre-existing mass, multiple peripherally displaced follicles with echogenic stroma, vascular pedicle twisting (whirlpool sign) and free pelvic fluid, is reported to be a common ultrasonographic finding in OT. Ovarian edema is most common among pregnant patients with OT compared to non-pregnant women . DopplerThe pathognomonic and most specific feature is a twisting of the ovarian pedicle, presenting as a beak-like protrusion adjacent to the ovarian mass or to the enlarged ovary. However, it is only identified in less than one-third of patients through CT and MRI ,94. In tIn this stage, gadolinium administration shows heterogeneous, minimal or absent perfusion, confirming the evolution toward necrosis; however, the administration of contrast medium should be avoided in pregnancy. Other findings include ipsilateral uterine deviation, a blood-filled fallopian tube  and a haemoperitoneum ,93,94,95MRI also represents the “gold standard” in the assessment of adnexal masses that remain indeterminate through US, having the best potential for the preoperative evaluation of these lesions. It has shown greater accuracy (88.9%) than US 63.9%) in the characterization of adnexal masses as malignant and a higher specificity (83.7% vs. 39.5%) .9% in th,99,100.MRI provides specific information about tissue content, including the presence of fluid, blood, fat and collagen. Signal hyperintensity on T1- and T2-weighted sequences is suggestive of intralesional fat or subacute blood products; in these cases, T1-weighted frequency-selective fat saturation pulse sequences should be obtained, enabling differential diagnosis between mature fat-containing teratomas and hemorrhagic cysts or endometriomas. Fluid-filled lesions show signal hypointensity on T1-weighted images and hyperintensity on T2-weighted images, as seen in functional cysts and cystic tumours. Masses showing low signal intensity on T1- and T2-weighted images likely contain collagen or hyalinized tissue, such as uterine leiomyoma, ovarian fibrotecoma and Brenner tumours ,101,102.Features such as prominent solid components within a cystic mass, necrosis in a solid mass or peritoneal implants are consistent with ovarian malignancies. Any cystic lesion should be carefully evaluated for mural nodules or septal thickening, as well as papillary projections, because these findings are suggestive of malignancy ,102,103.Most ovarian masses diagnosed in pregnancy are benign and are spontaneously resolved . SurgicaUterine leiomyoma is the most common tumour of the female reproductive tract, affecting 70–80% of patients during their lifetime. The prevalence of leiomyomas in pregnancy is estimated to exceed 11%, with higher frequency in advancing maternal age ,105.Leiomyomas are often asymptomatic during gestation; however, the physiological enlargement of the uterus can outgrow the vascular supply, resulting in hemorrhagic infarction of the leiomyoma (red degeneration). This condition, causing acute abdominal pain, occurs secondary to venous thrombosis, within the periphery of the fibroid . US is tThe US features of leiomyoma are a spherical, well-defined, solid mass, usually hypoechoic compared to the surrounding myometrium. In red degeneration, US shows heterogeneous or hyperechoic lesions and, later, anechoic components, reflecting cystic changes. The Doppler US demonstrates a decreased or absent flow . MRI couLeiomyoma with red degeneration (RDL) may show an unusual signal intensity pattern on MRI. On T1-weighted images, RDL may exhibit diffuse high-signal intensity  or a chaOn T2-weighted images, the signal intensity may be variable with a peripheral low-intensity rim, which is also characteristic of RDL; this finding is secondary to the T2*-shortening effects of deoxyhemoglobin, intracellular methemoglobin or hemosiderin of blood products, as well as the expression of venous thrombosis ,107,108.RDL shows a lack of enhancement following gadolinium administration, although contrast is generally not administered during pregnancy .Post-partum ovarian vein thrombosis (OVT) is an uncommon but potentially serious disorder during pregnancy and, most often, during puerperium. OVT is reported in approximately 0.05% to 0.18% of vaginal births and in 2% of cases after cesarean delivery . MoreoveClassically, OVT arises in the first 7 days post-partum and is characterized by lower abdominal or flank pain, fever, leucocytosis and, much less commonly, a palpable pelvic mass. Both venous stasis and hypercoagulability place pregnant patients at increased risk of venous thrombosis .OVT is right-sided in almost 90% of cases due to the compression of the inferior vena cava and right ovarian vein by the dextrotated uterus during pregnancy. Other contributory factors include the length of the right ovarian vein, the lack of retrograde flow and multiple incompetent valves. Both ovarian veins may be affected in 14% of cases ,111.A prompt diagnosis and treatment of OVT are crucial to avoid potentially life-threatening complications such as septic thrombophlebitis, ovarian infarction, ureteral obstruction, hydronephrosis, renal failure and extension of the thrombus into the inferior vena cava, leading to a pulmonary embolism .US may be employed as a first-line imaging modality, due to its safety, low cost and wide availability.US features of OVT include an anechoic or hypoechoic tubular structure in the region of the right adnexa and inferior vena cava, with an intra-luminal echogenic mass . Color DHowever, US is an operator-dependent imaging modality and can often be inconclusive due to body habitus or overlying bowel gas, which reduce the detection rate of US .CT with intravenous contrast represents the modality of choice for the diagnosis of OVT post partum, assessing the extent of the thrombosis within the renal vein and the inferior vena cava. A thick-walled, enlarged ovarian vein with rim enhancement and an intra-luminal central filling defect are the main imaging findings of OVT . MultiplIn a pregnant patient, the ionizing radiation limits the employment of CT ,114. NonDetermining the cause of acute abdominopelvic pain in pregnancy and puerperium is challenging on clinical grounds alone. Urgent imaging is often required, playing an essential role in the assessment of these complications. US followed by MRI are techniques of choice because of their safety profile for both the mother and the foetus. However, US may be limited by altered body habitus, the small field of view and the presence of interfering overlying structures. MRI is extremely accurate in identifying both obstetric and non-obstetric diseases, owing to its superior field of view and soft tissue contrast. CT should be considered in pregnancy on a case-by-case basis if it is likely to offer a high diagnostic yield in problem-solving. Conversely, CT is the imaging modality of choice in patients with post-partum acute abdominal pain, especially after a non-diagnostic US. Comprehensive knowledge of common and uncommon pregnancy and puerperium complications and their imaging features is crucial for accurate diagnosis and early treatment.


Primary calvarial boney tumors are generally rare in clinical practice. Multiple primary skull neoplasms are less frequent, typically associated with genetic disorders or familial syndromes. Sporadic cases of multiple skull tumors are exceptionally rare. We present a unique scenario of a 32-year-old female patient who had two right-sided skull vault lesions, one located over the right parietal area and the other in the right retro-auricular region. The lesions exhibited different behaviors over several years. The workup revealed that the two skull lesions were of two pathologies. The standard academic approach for clinical analysis attributes the symptoms often to one pathological process until proven otherwise. This case highlights the significance of expanding the differential diagnoses and incites clinicians to consider multiple pathologies in specific clinical settings. Skull tumors are uncommon neoplasms, accounting for approximately 2% of musculoskeletal tumors . Among bA 32-year-old female patient presented to our neurosurgery clinic with two right-sided scalp swellings over the right parietal and retro-auricular regions. She had no previous history of trauma, no significant past medical or surgical history, and no family history of bone or soft tissue tumors. The first mass was noticed in the right retro-auricular region when she was a teenager, causing no other symptoms. At that time, she underwent a brain computed tomography (CT) scan, and the mass was labeled as an osteoma arising from the mastoid part of the temporal bone. No further treatment was recommended. Four years later, she underwent a follow-up brain CT scan, and the previous mass did not show any significant changes. However, she was found to have another mass in the right parietal bone. Eight years later, when she became pregnant, the patient reported that the parietal mass was getting larger in size, but the retro-auricular mass remained the same. Five years later, the parietal lesion became larger and was associated with continuous right ear tinnitus, right-sided headache, and disfiguration of her skull shape. Her family history was negative for genetic diseases or bone tumors. After performing a brain CT scan, she was found to have a small right mastoid osteoma with an ipsilateral large parietal cavernous hemangioma . The scalp was meticulously opened in layers, and the pericranium was gently detached from the outer surface of the parietal mass and the surrounding normal bone, maintaining a safe margin. Subsequently, the mastoid mass was exposed and excised in one piece, including the outer table of the mastoid bone, using a chisel Figure , Panel AA synthetic flap made of methyl methacrylate was fashioned and used to reconstruct the skull defect. Titanium burr-hole cover plates, mini plates, and mini screws were employed to secure the new synthetic flap to the surrounding normal bone. The galea was reapproximated, and the scalp was closed in layers. The patient experienced an uneventful postoperative recovery.The patient underwent regular follow-up visits in the initial year after the surgery and subsequently annually. Her follow-up was conducted over a four-year period, during which there were no indications of recurrence observed, both in terms of clinical examination and radiological assessments  gene mutation (a tumor suppressor gene), and the results were negative. There was no history of familial syndromes or genetic disorders in the family.Skull bone tumors (osteomas and cavernous hemangiomas) are rare human neoplasms, accounting for less than 2% of all musculoskeletal malignancies ,2. The sOsseous hemangioma is a slowly growing benign vascular bone tumor, accounting for less than 1% of primary bone lesions and 10% of benign calvarial tumors -9. The fThe synchronous occurrence of different benign skull tumors is extremely rare, particularly in sporadic cases. However, multiple skull tumors are associated with certain syndromes. For instance, Gardner's syndrome, an autosomal dominant inherited disease and a form of familial adenomatous polyposis, can present with multiple skull osteomas . Ollier'In the present case, surgical resection was performed to remove two skull lesions with different pathological characteristics. The gross and microscopic examinations provided valuable insights into the nature and features of these lesions. The parietal mass was confirmed as a cavernous hemangioma, exhibiting a highly vascular nature. Cavernous hemangioma increased in size and became more symptomatic during pregnancy, which could be attributed to several factors. First, the increase in the intravascular volume and associated hemodynamic changes during pregnancy could result in vascular channel expansion within the hemangioma. Second, the hormonal fluctuation namely high progesterone level can augment vascular volume and high estrogen can upregulate endothelial proliferation . The retRegular follow-up examinations showed no evidence of recurrence for the excised lesions. The clinical behavior of sporadic cases of surgically managed multiple skull lesions, whether benign or malignant, remains largely unknown. However, in familial cases, many skull tumors have shown a more malignant course -18. FurtWe presented a case with two skull masses, where both radiological and histological findings confirmed the simultaneous presence of a bony cavernous hemangioma and calvarial osteoma. While conventional academic case analysis typically attributes symptoms to a single pathology, clinicians should broaden their differentials in complex clinical scenarios. This case report underscores the importance of scrutinizing intricate cases with multiple skull lesions. Accurate diagnosis and appropriate treatment are essential in effectively managing these cases.


Vascular ectasias are characterized by abnormal blood vessel enlargement and presumed to be caused by degenerative processes. About 3% of lower gastrointestinal bleeding is caused by it. On endoscopy, colonic arteriovenous malformations are frequently solitary, sizable, flat, or raised red lesions. Conversely, colonic vascular ectasia that manifests as pedunculated polypoid lesions are rare.A 45-year-old woman presented with hematochezia and abdominal pain. Abdominal ultrasound and Contrast enhanced computed tomography abdomen, both showed features of ileocolic intussusception. Intraoperatively, an intraluminal pedunculated polypoid growth extending up to the hepatic flexure of the colon was discovered. A right hemicolectomy was performed, removing the polypoid growth as well. After histopathological evaluation, a final diagnosis of colonic polypoid vascular ectasia was made.Gastrointestinal bleeding is the common initial manifestation of vascular ectasia, while some individuals may continue to be asymptomatic. According to a study from July 2022, vascular ectasia that manifests as polypoid growth is an uncommon phenomenon that has only been documented in 17 other cases. An intussusception may have a polypoid vascular ectasia as its lead point. Conversely, a large polypoid vascular ectasia may have radiographic characteristics that resemble an intussusception.Large colonic vascular ectasia, which tends to enlarge over time, can occasionally be misinterpreted as an intussusception due to comparable radiological appearances. In the event that a polypoid colonic vascular ectasia is misidentified for intussusception, the surgical team must be ready to adjust the treatment protocol as needed. HighlightsA 45-year-old woman presented with blood-stained stool and right lower abdominal pain.The target sign or doughnut sign seen on both the contrast enhanced computed tomography and the ultrasonography led to the presumptive diagnosis of ileocolic intussusception.Intraoperatively, intraluminal polypoid growth measuring ~14×2.5×2 cm arose adjacent to the ileocaecal opening which extended up to the hepatic flexure of the large intestine.Right hemicolectomy along with end-to-end bowel anastomosis was performed.After histopathological evaluation, a final diagnosis of colonic polypoid vascular ectasia was made.1. Particularly in the elderly, it is a common cause of lower gastrointestinal bleeding. Usually, they appear as reddish lesions that are flat or slightly elevated. Conversely, colonic VE presenting as pedunculated polypoid lesions are rare2 and commonly misidentified for atheroemboli-associated polyps or inflammatory fibroid polyps3. The ascending colon or caecum is frequently affected in older patients with vascular ectasia or angiodysplasia, the most common gastrointestinal (GI) vascular malformation4. Despite the rarity of colonic vascular ectasia manifesting as a pedunculated polypoid growth, we report a case in a 45-year-old female where a polypoid colonic vascular ectasia mimicked an ileocolic intussusception. The primary learning goal of our shown instance is the potential for such imitating phenomena.Colonic vascular ectasias (VE), commonly referred to as arteriovenous malformations (AVMs) or angiodysplasia, is a disorder characterized by aberrant blood vessel enlargement that is thought to be brought on by degenerative changes Supplemental Digital Content 1, http://links.lww.com/MS9/A143.Guidelines: SCARE 2020 paperThis case has been reported in line with the SCARE criteria.A 45-year-old female presented to the emergency with complaints of blood-stained stool for 1 day. The patient was apparently well until 7 days back when she developed pain over the right lower abdomen. The pain was colicky in nature, moderate intensity, and non-radiating, with no aggravating or relieving factors. The pain was associated with vomiting for 2 days which was non-bilious, occurred two to three times per day, and contained only food particles. On further inquiry, the patient reported having constipation for 6 months which occurred in an on-and-off pattern. She did not report any pain during defecation nor any protruding mass per rectum. There was no history of melena, anorexia, weight loss, or fever.No significant past medical and surgical history.No family history of similar presentations exists.No significant drug and allergy history. The patient denied the use of tobacco or illicit drugs.On examination, the patient was alert with stable vital signs. The abdomen was soft with tenderness present over the right iliac fossa. No guarding, rigidity, or rebound tenderness was noted. No organomegaly or lump was palpable. The bowel sounds were increased. Hernial orifices were intact. Blood-stained faeces were found during a Digital Rectal Examination (DRE). DRE was normal in all other aspects. The rest of the general and systemic examinations were within normal limits.http://links.lww.com/MS9/A144). A provisional diagnosis of ileocolic intussusception was made.Laboratory studies showed haemoglobin levels of 8.6 gm/dl. Other blood investigations were unremarkable. Abdominal ultrasonography revealed a “target sign”, possibly due to the telescoping of the terminal part of the ileum into the caecum. The patient underwent a contrast enhanced computed tomography abdomen which revealed features suggestive of telescoping of the distal ileum into the caecum and ascending colon, measuring a total intussusception length of 13 cm (Figs. The decision to operate on the patient was validated by the imaging findings. Intraoperatively, the terminal ileum and caecum looked normal with no telescoping of the bowel loops. An intraluminal mass with firm consistency was palpated. On further exploration, an intraluminal polypoid growth measuring ~14×2.5×2 cm arose adjacent to the ileocaecal opening which extended up to the hepatic flexure of the large intestine Figs.  and 4. RThe patient followed up 2 weeks later with the histopathology report which showed vascular ectasia Figs.  and 6. S6. According to their morphology, VE is made up of dilated, thin-walled vessels in the mucosa and submucosa that are lined entirely or mostly by endothelium along with a small amount of smooth muscle8. The leading hypothesis is that these lesions grow with age as a result of intermittent and recurrent mucosal and submucosal vein occlusion brought on by increased contractility at the level of the muscularis propria. The prolonged obstruction causes vascular dilatation and arteriovenous shunts by increasing pressure and congestion in venules and capillaries10.VEs are a type of acquired AVM that differs from neoplastic and congenital lesions. They can occasionally affect younger persons but more frequently affect elderly patients as the cause of occult, recurrent, or severe colonic haemorrhage3. Hematochezia is the primary concern in 60% of patients with colonic AVMs, while 25% of the lesions are asymptomatic in the elderly and discovered during a screening colonoscopy4. Similar to our patient, the main reason for the hospital visit was hematochezia. Her haemoglobin was 8.6 gm/dl at evaluation. She had, however, never undergone a screening colonoscopy before. The incidence of vascular ectasia is increased in people with comorbid conditions such as aortic stenosis, Von Willebrand disease, and chronic kidney illness11.Clinic visits and hospital stays are frequently caused by GI bleeding from the colon. About 3% of lower GI bleeding is caused by vascular ectasias2. In our case, the vascular ectasia presented as a pedunculated polypoid growth measuring a size 14×2.5×2 cm. The vascular ectasia’s polypoid growth presentation turned out to be a rare occurrence in and of itself, and the case’s rarity was further enhanced by the growth’s dimensions. The growth originated near the ileocecal opening and extended up to the colon’s hepatic flexure, resembling an ileocolic intussusception on radiographic imaging. According to a thorough assessment of the literature and to the best of our knowledge, the current case appears to be the largest polypoid vascular ectasia ever documented.Submucosal vascular ectasias presenting as pedunculated polypoid lesions, which are uncommon and have only been described in 17 other cases in the literature, are different from flat or slightly raised classical vascular ectasias, which are reported in 1–6% of colonoscopies, according to a study from July 202213. In contrast to intussusception in children, intussusception in adults is exceedingly rare, and the majority of cases are secondary14. Imaging modalities are necessary for a firm diagnosis. The target or doughnut sign on an ultrasound verifies the diagnosis. The hyperechoic central core of the bowel and mesentery is surrounded by the hypoechoic outer oedematous bowel, creating a doughnut-shaped image on transverse sonography or computed tomography. Intussusception may look like a sandwich when viewed in longitudinal imaging15. An intussusception may have a polypoid vascular ectasia as its lead point16. In our situation, the axial reformation of the contrast enhanced computed tomography as well as the ultrasonography both showed the target sign or doughnut sign, leading to a presumptive diagnosis of ileocolic intussusception. The likelihood of this imitating phenomenon may result from the intussusception’s common site of occurrence as well as from the polypoid vascular ectasia’s thin-walled tubular structure.When one intestinal segment telescopes into an adjacent intestinal segment, it is called an intussusception2. But, in our situation, the pertinent history, examination, and radiographic evidence of ileocolic intussusception led to a decision to perform laparotomy, only to discover normal bowel walls devoid of any telescoping, as well as a large intraluminal pedunculated polypoid growth for which bowel resection was done along with the polypoid growth.In previous studies, an endoscopic snare polypectomy was mostly used to remove the polypoid vascular ectasiaBoth from the patient’s and the physician’s perspective, challenges, difficulties, and limitations were noted. Due to the typical radiographic findings and clinical manifestations, we were unable to appropriately diagnose this case preoperatively. A rapid pathological investigation would have changed the care plan, but our surgical setting did not permit it. Financial obstacles and follow-up compliance issues, such as the patients’ remote residential location, were present from the patient’s perspective.Vascular ectasias are caused by degenerative processes, and they may enlarge as the patient ages. Colonic vascular ectasia that manifests as pedunculated polypoid growth is a very uncommon occurrence. A large colonic vascular ectasia could mimic an intussusception, both clinically as well as radiographically. When a surgeon operates on an adult patient with a diagnosis of ileocolic intussusception, even though it is a rare occurrence, this possibility may need to be kept in mind to make the required preoperative and intraoperative treatment modifications.None.Written informed consent was obtained from the patient for the 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.This case has not been funded by any person or any institution.U.R.: conceptualization, methodology, writing—original draft preparation, software, project administration. S.T.: data curation, writing—original draft preparation, software. G.S.: visualization, writing—reviewing and editing. S.S.: supervision, visualization: U.K.: validation, supervision, conceptualization.None.Utsav Karki.NA.Not commissioned, externally peer-reviewed.


Invasive cervical resorption (ICR) is a phenomenon of unknown etiology that results in the loss of hard dental tissue. To have a successful outcome for a tooth affected by ICR, correct diagnosis and management are needed. With the introduction of new biocompatible materials and the advancement of CBCT imaging, these pathologies can be identified and treated with precision, resulting in promising outcomes. This case report aims to present the management of maxillary central incisors diagnosed with external ICR, treated with bioceramic root repair material, and followed-up to six years. Root resorption is the loss of hard dental tissue (cementum and dentin) due to odontoclastic activity. Root resorption can be classified, based on its proximity to the root surface, as internal or external resorption. External cervical resorption is the type of root resorption that initiates on the external surface of a tooth at the cervical area and causes the replacement of mineralized structure with fibrovascular tissue or fibro-osseous tissue. The rapid loss of cementum and dentine in an invasive manner necessitates careful management to arrest the resorptive process. Understanding the etiology and pathogenesis of such a type of resorption is very important for its management. Pathologic tooth resorption is classified into external resorption and internal resorption. External resorption is further classified into external inflammatory resorption, external cervical resorption (ECR), external replacement resorption, and transient apical breakdown.1Due to its unclear etiology, several terms have been used to describe ECR such as invasive cervical resorption (ICR)10Heithersay et al. classified ECR into four classes. Class one describes a small invasive lesion located cervically, Class two designates a well-defined invasive resorptive lesion penetrating close to the coronal pulp, Class three a more profound invasion of coronal dentine, and coronal one-third of the root, and lastly, Class four defines a large invasive resorptive lesion extending beyond the coronal third of the root.Various bioceramic materials have been used in the management of cervical resorption, such as mineral trioxide aggregate (MTA), glass-ionomer cement (GIC), and calcium-enriched mixture (CEM).17This case report describes the non-surgical and surgical management of external cervical resorption affecting upper central incisors with six years of follow-up clinically and radiographically by CBCT.A 55-year-old female patient presented at the University dental clinic with the chief complaint of generalized bleeding from gums and bad breath. The medical history of the patient was non-contributory. The patient had undergone orthodontic treatment 18 years ago. She had also received multiple restorations in the past. The extra-oral examination didn’t reveal any deviation from normality. Generalized bleeding on probing with clinical attachment loss was noted on intraoral examination. The radiographic examination suggested generalized bone loss. The periodontal diagnosis was stage two with grade two periodontal disease. Additionally, during the radiographic examination, areas of rarefaction were noticed in the cervical areas of upper central incisors on periapical radiographs  After thThe endodontist examined the upper central incisors. Both central incisors were of normal color and responded normally to cold test. Furthermore, no discomfort, sensitivity, and swelling were noticed on percussion and palpation test . ProbingThe shifted radiographs showed that the lesion projection remained at its position in relation to the canal and the outline of the canal was not disturbed . For fur). In contrast, due to patient’s time constraints, for tooth #21 the pulp space was maintained by a single cone of X5 to be obturated after surgery. The access cavities for both central incisors were sealed by temporary restorations Cavit   was administered as local anesthesia by buccal infiltration technique. Rubber dam isolation was performed for the maxillary central incisors. Teeth #11 and #21 were accessed, cleaned, and shaped using 2.5% sodium hypochlorite as irrigant and ProTaper Next  up to file size X5. After drying the canals with paper points, obturation of the apical portion of tooth #11 was achieved by continuous wave technique by System B using gutta-percha and zinc oxide sealer  .On the day of surgery, following the administration of 2% lidocaine with 1:100,000 epinephrine (Septodont) by infiltration technique and incisive nerve block, a palatal sulcular incision was performed from the right canine to the left canine. A flap was reflected to expose the cervical area of the palatal surfaces of central incisors. Under magnification , the granulation tissue was removed from both teeth, and the defect surfaces were excavated and smoothened with a round bur. After that, a cotton pellet soaked in 90% Trichloracetic acid (TCA) was applied to the defect for five minutes. Following the surface treatment by TCA, the necrotic tissue was removed, and the cavity was excavated with a round bur . Afterward, the defect cavities were filled and restored with a Putty Bioceramic restorative material . Finally, the flap was repositioned, and interrupted sutures were placed. The temporary filling of tooth #21 was removed for final obturation by continuous wave technique followed by injectable thermoplasticized gutta-percha backfilling the coronal canal space. The patient was referred to the restorative department for final coronal restoration . SubsequThe patient presented after six years to seek treatment for another distant symptomatic tooth. At this appointment, the patient’s maxillary incisors were re-evaluated clinically and radiographically, six years post-treatment. . The teeThis report described the management of ECR commencing from examination and diagnosis to treatment and restoration of the resorptive defect. It has been known that ECR is not easily recognized since most of the cases are asymptomatic like the present case where the pulp responded normally to cold test with no pain or tenderness on percussion and palpation. The accidentally discovered resorptive radiolucent lesion over the canal on a periapical radiograph can be differentially diagnosed as external resorption or internal resorption. Since each has a different origin and pathogenesis, it is crucial to identify the type of resorption present in order to manage the case properly.A radiographic assessment was necessary for ICR diagnosis. Considering the difficulty in differentiating the ICR lesions from internal root resorption, a CBCT image was taken. CBCT offers a superior imaging technique that allows a better understanding of the lesion behavior and aids in diagnosing the exact type of resorption through a 3-D assessment.2Regarding ICR treatment, proper management of each case is essentially related to its etiology. In this case, the patient had a previous history of orthodontic treatment for correction of inclination of anterior teeth and closure of diastema. Orthodontic treatment is found to be one of the most significant etiological variables, causing 24.1% of ICR lesions.2Several authors have proposed various treatment methods for ICR. The primary goal of ICR treatment is to remove resorptive tissue altogether and to restore the damaged area. The present case depicts a cervical resorptive defect that needed root canal treatment followed by sealing of the resorptive site with Bioceramic using a surgical approach. Different materials can be used for the restoration of defects, such as MTA, resin-modified GIC, and CEM.23The success rate of management of ECR differs depending upon the degree of resorption. Heithersay reported a 77% success rate of Class three lesions if all factors such as resorption control, periapical changes, bone loss, and extraction have been evaluatedThe findings of this report emphasize the importance of longer follow-up, using CBCT for monitoring the outcome of ECR as well as proper diagnosis and preoperative assessment to establish a comprehensive treatment strategy aiming to arrest the resorptive process and prevent recurrence. Moreover, the utilization of contemporary management strategies including Dental Operating Microscope and TCA/ bioceramic material did not guarantee the prevention of ICR recurrence. This highlights the need for further research to look for more effective methods for the management of the disease.MQJ is responsible for the integrity of the work.All authors have contributed significantly towards the manuscript, and all authors are in agreement with the manuscript.


Primary mesenteric liposarcoma is a rare soft tissue malignant neoplasm. The authors present a case of a 42-year-old male with pain in the abdomen and abdominal mass which showed a desmoid tumor on biopsy and CT shows a mesenteric mass present. The patient underwent exploratory laparotomy and a large tumor was excised. The specimen was sent for histopathology and showed dedifferentiated liposarcoma of the mesentery. Immunohistochemistry showed the tumor cells are diffusely positive for mouse double minute 2 (MDM2), p16, and show patchy positivity for the cluster of differentiation (CD) 34. The cells are negative for smooth muscle actin (SMA), desmin, S100, and ckit. After the surgery, the patient recovered well and was given adjuvant chemotherapy with doxorubicin, ifosfamide, and mesna. The patient has no signs or symptoms of recurrence to date. In this case, the combination of surgery and chemotherapy has shown to have a good clinical outcome. Liposarcoma (LPS) is a malignant soft-tissue tumor whose incidence peaks in the fourth to sixth decade of life  and is uA 42-year-old male patient presented with a history of pain in the left side of the abdomen for the past two months. There was no history suggestive of abdominal mass, significant weight loss, anorexia, gastric outlet obstruction, altered bowel habits, malena, or urinary complaints. The patient had a history of pulmonary tuberculosis five years back for which he received treatment. The patient also underwent right inguinal hernioplasty four years back. He is a chronic tobacco chewer for the past 15 years.On examination of the abdomen, a large, intra-abdominal, mobile mass was found which is well defined, hard in consistency, non-tender, approximately 10cm × 9cm in size occupying the left hypochondrium and left lumbar region of the abdomen  measuring 12.6cm × 13cm × 14.7cm noted within the mesentery of the left lumbar region. There is no evidence of early arterial enhancement seen. The lesion was limited anteriorly by the anterior abdominal wall, medially displacing the small bowel loops and posteriorly pushing the descending colon. No calcification was seen  and necrosis noted. The stroma showed myxoid change and delicate branching vessels. The tumor is seen infiltrating the adipose tissue in the periphery. The capsule is seen free of tumor. Focal lymphoid aggregates are noted. On immunohistochemistry, the tumor cells were diffusely positive for mouse double minute 2 (MDM2), p16 and showed patchy positivity for cluster of differentiation (CD) 34 and negative for smooth muscle actin (SMA), Desmin, S100, and ckit.This patient had an uneventful post-operative period and was discharged on postoperative day seven. The patient has completed five cycles of chemotherapy post-operatively. The patient was given an injection of doxorubicin 40mg, an injection of ifosfamide 4gm, and mesna 960mg on days one, two, and three of each cycle of every 21 days. The patient is currently in the sixth month of follow-up with no symptoms or signs of recurrence.Primary mesenteric liposarcomas are rare neoplasms that are similar to liposarcomas occurring in other sites of the body: these lesions mostly occur in the fifth to seventh decade of life with males getting slightly more affected -8.The clinical presentation depends on the size and location of the tumor. They become clinically symptomatic in view of sheer size or compression on adjacent organs. The finding of a freely mobile mass on physical examination is frequent and can help in the diagnosis ,7. PatieFor diagnosis, CT scans can provide important information regarding the size and involvement of adjacent structures as well as tissue characteristics of the tumor -13. The In our patient, a CT scan showed a well-defined, lobulated, heterogeneously enhancing, solid lesion likely arising from the mesentery. There is no evidence of early arterial enhancement seen. The lesion was limited anteriorly by the anterior abdominal wall, medially it was displacing the small bowel loops and posteriorly it was pushing the descending colon. No calcification was seen.WHO classifies liposarcoma into various subtypes: well-differentiated, pleomorphic, myxoid, round cell, and dedifferentiated . The mosThe treatment for mesenteric liposarcoma consists of a tumor excision with clear margins followed by adjuvant chemotherapy and/or radiotherapy in patients who are at high risk of recurrences such as large tumor size (>5cm) or poorly differentiated tumors . It is rThe drug used for chemotherapy is doxorubicin. It is shown in 14 randomized trials that adjuvant doxorubicin-based chemotherapy significantly decreases the local and distant recurrence and tends to improve the overall survival rate of patients . AnotherPrimary mesenteric liposarcoma is a rare entitiy. CT and MRI are important radiological investigations in finding the characteristics of the tumor, the tumor size, and the presence of any invasion into the surrounding structures. The tumor is often resectable and the treatment of choice is surgery with resection of the tumor followed by adjuvant chemotherapy and/or radiotherapy. Histological classification and tumor site and size determine the prognosis of the patient while positive surgical margins are associated with an increased risk of local recurrence. The patient should be followed up to assess the role of chemotherapy and to detect recurrence as the rate of recurrence of liposarcomas is high.


The diagnosis and management of tracheobronchial papilloma is challenging due to its rarity, and non-specific presenting symptoms. Small percentage undergoes malignant transformation. Herein, we report an unusual case of tracheal papilloma initially misdiagnosed as chronic obstructive pulmonary disease (COPD) in 36-year-old male with triple Y syndrome. It was successfully treated with local debridement and brachytherapy. To the best of our knowledge, this is the first description of brachytherapy for such a condition. Papilloma is a benign neoplasm, most commonly occur in the genitalia or the oral cavity. Usually in relation to human papilloma virus (HPV) infection. It rarely affects the airways, predominantly involve the larynx, however, involvement of the trachea has been reported to be around 5% of the cases , 2. TripA 36-year-old male with 48, XYYY karyotype and 15-pack-year smoking history presented with 2-year history of progressive dry cough, raspy breathing, and dyspnea. His past medical history include developmental delay, attention-deficit/hyperactivity disorder (ADHD), gastroesophageal reflux disease (GERD), behavior disorder , and obesity. He was initially treated as a case of chronic obstructive pulmonary disease (COPD), however, he did not improve, as such further investigations were carried out. He underwent bronchoscopy, which revealed irregular, lobulated tissue starting from the fourth tracheal ring throughout the entire trachea, extending into the bronchus intermedius with near total obstruction  intubated and sedated with no inotropic support. A bronchoscopy was repeated which showed one residual area of a small papilloma in the mid trachea, originating from the membranous part. The rest of airways were clear and patent. He was extubated, transferred to the ward in a stable condition, then discharged home few days later.Histopathological examination revealed squamous papillary lesion with focal carcinoma in situ and p16 immunohistochemistry negative. He was thereafter referred to radiation oncology and underwent brachytherapy (two fractions of 700 cGy) with a good clinical and endoscopic response. He remains well 6 months after treatment, no recurrence.This is an unusual case for several reasons: presentation with solitary tracheobronchial papilloma which is rare compared to papillomatosis of upper respiratory tract; the existence of malignant transformation which is uncommon at 3–7% of patients  , 5 and eThe clinical presentation is variable which make the diagnosis more challenging. Bronchoscopy could be both diagnostic and therapeutic in some cases. Respiratory papillomatosis is primarily treated by resection surgical or endoscopic. Other treatment modalities include laser therapy, interferon α, external beam radiation or photodynamic therapy . The goaBecause of the location of the papilloma in the airway, the team should be prepared in case inadvertent events happened such as pneumothorax that likely occurred during the jet ventilation during the case. It is essential to discuss the case and the operative procedure with the anesthesia team prior to surgery to plan the airway management intraoperatively.Given the rarity of the tracheal papillomatosis, most of the information were based on case reports. Local recurrence might happen, as such close follow up is important. However, there are no guidelines regarding the surveillance post resection, further studies are needed.Primary tracheal papilloma is rare. Usually, patients present with non- specific respiratory symptoms, as such high clinical suspicion is needed. We recommend CT scan and bronchoscopy to establish the diagnosis. We report a successful treatment with local therapy using endoscopic debridement followed by brachytherapy. The main treatment is resection, however, the rule of adjuvant therapy needed to be studied further.


Streptococcus sanguinis. She underwent primary repair of the atrial defect on cardiopulmonary bypass where a large atrial vegetation was retrieved, followed by a right thoracotomy with the closure of the esophageal defect the next day. She was discharged to a rehabilitation facility after 18 days of hospital stay with a 6 weeks antibiotics plan. The incidence of AEF following ablation procedures has been estimated at 0.01 to 0.04%, and the pathogenesis is linked to direct tissue and vagus nerve injury. The most common clinical findings are fever and neurologic deficits. CT chest is the best diagnostic modality. CT head might demonstrate embolic phenomena and TTE can show vegetation. Early surgical intervention, even in an unstable patient, is paramount for survival.A 66-year-old female with a history of radiofrequency ablation for atrial fibrillation presented with hematemesis and fever. A CT chest revealed an atrio-esophageal fistula (AEF) and a CT head showed bilateral septic emboli. Blood cultures were positive for  Atrio-esophageal fistula (AEF) is a rarely seen but known complication of catheter ablations, with an estimated mortality of 40-100%. In this case, I describe the natural history of a patient presenting with AEF and summarize the pathogenesis, diagnostic strategies, and management options before discussing recently proposed prevention strategies. Absence of guidelines results in a medical and surgical lack of expertise on how to approach these patients. This case is aimed at bridging a potential knowledge gap and emphasizing the importance of early surgical intervention as seen in prior reviews.A 66-year-old female with a history of gastric sleeve, paroxysmal atrial fibrillation on apixaban, status postradiofrequency ablation 4 weeks prior to presentation, hypertension, diabetes mellitus, and obesity, presented to an outside hospital with hematemesis and chills. Her vital signs were significant for the temperature of 103.1, and a chest CT with contrast revealed a left atrium to esophageal fistula. She had last taken apixaban the morning of admission. She was given prothrombin complex concentrate (PCC) and transferred to a tertiary center's cardiovascular intensive care unit (CVICU) for a higher level of care.Streptococcus sanguinis and broad spectrum coverage with fluconazole, vancomycin, and piperacillin/tazobactam was continued pending susceptibilities. The following day, she underwent primary closure of the left atrial defect. Intraoperative findings were significant for a 4 cm × 1.5 cm vegetation in the left atrium at the base of the endocardial defect  is a rare complication of surgical or percutaneous ablation procedures. Although esophageal thermal lesions have been reported frequently, the incidence of complete atrio-esophageal fistula has been estimated at 0.01 to 0.04% based on surveys with variable participation , and morIn a systematic review of 52 cases by Chavez et al., fever, neurologic deficits, and hematemesis were the most common presenting symptoms;  this corMost authors agree that CT chest with IV contrast is the best diagnostic modality due to its low cost and high sensitivity . SeveralThe prompt evaluation and referral to a higher level of care were keys to a successful outcome in this case. Once AEF has been identified, surgical intervention should be considered. A review by Yousuf et al. showed that mortality was 100% for patients managed with medical therapy or esophageal stenting alone, including the ones who died before planned surgical intervention . A multiReported surgical interventions vary in the literature, with most specialists choosing a pleural or intercostal muscle flap for esophageal repair during the index operation to repair the atrial defect with or without cardiopulmonary bypass or shortly after via thoracotomy. , 16 The In a case series of five patients, Kim et al. reported a successful case of a massive defect with air leak managed with VA ECMO-induced ventricular fibrillation in the preoperative period to minimize the risk of embolism; this could be considered as a transitory measure in a center with ECMO capabilities if the operating room or surgical team are not immediately available , but thiRoutine esophageal temperature monitoring and periprocedural use of proton pump inhibitors are considered standard preventative measures in many centers. Unfortunately, the low incidence of this complication translates into the lack of high-quality randomized evidence for their efficacy in preventing injury.The significant morbidity and mortality associated with atrio-esophageal fistulas have led to a growing interest in preventative methods. Different techniques have been identified in recent years, with esophageal cooling devices becoming an attractive cost-effective option. In a randomized comparison between an esophageal cooling device with standard temperature monitoring, the intervention group had fewer thermal injuries on endoscopic examinations at one week follow-up when the esophageal temperature was maintained at 4 degrees Celsius throughout the ablation procedure . Other nGiven the widespread implementation of catheter ablation as an attractive therapeutic option performed for more indications at more centers with different energy forms, it is likely that atrio-esophageal fistulas will occur in some cases. High-clinical suspicion of patients presenting with fever, hematemesis, and neurologic symptoms up to two months after AF ablation is important for survival.


Cardiac masses are rarely encountered in clinical practice and can lead to severe hemodynamic consequences. In addition to clinical cues, noninvasive modalities can play an important role in characterization of these masses and therefore their diagnosis and management planning. Here in this case report, we describe the use of various forms of noninvasive imaging techniques to narrow the differential diagnosis and form an operative plan for a cardiac mass later identified as a benign myxoma originating from the right ventricle on histological examination. Cardiac masses were traditionally identified only during autopsy findings; however, with the advent of widely available noninvasive imaging techniques, their diagnosis has become easier and their management a reality . AdvanceA female patient in her 60s with a medical history of hypertension followed up with her primary care physician for an annual physical examination. Upon evaluation, the patient denied any complaints, and a review of the system was negative for any symptoms. Cardiac auscultation revealed a regular rate and rhythm with a III/VI systolic murmur best heard at the apex. The rest of her examination and vitals were normal. The electrocardiogram demonstrated normal sinus rhythm with no abnormalities. A transthoracic echocardiogram (TTE) was ordered to evaluate the etiology of the systolic murmur which demonstrated moderate concentric left ventricular hypertrophy with normal cavity size and ejection fraction. A mobile, pedunculated mass was seen extending from the undersurface of the tricuspid annulus and traversing the pulmonic valve into the main pulmonary artery with mild right ventricular (RV) dilatation and hypokinesia . A gatedPathology confirmed a smooth glistening gelatinous tan-red mass measuring 7.0 × 2.0 × 3.0 cm. Microscopically, the lesion consisted of bland cells in a basophilic matrix with a few spindle cells. No lipoblast or mitotic activity was noted. Ancillary testing using immunohistochemical stains was positive for calretinin, supporting the diagnosis of myxoma with excised margins negative for tumor .Cardiac masses are rare and may include tumors, thrombi, vegetations, or calcific lesions which unlike other organs can have severe hemodynamic consequences due to obstruction, embolism, electrical, or mechanical dysfunction . CardiacCardiac MRI with its tissue characterization and ability to provide information about extracardiac structures can help in assessing cardiac masses. First-pass perfusion to assess vascularity (high for vascular structures) and late gadolinium enhancement (absent in thrombus) can help to differentiate tumors from thrombus. T1 and T2 mapping along with other features can also help to differentiate between types of tumors , 5. CardThis case therefore not only describes a rare case of an incidental myxoma from the right ventricle but also shows how multimodality noninvasive imaging can be used to differentiate masses, aid in the management of these patients, and provide excellent correlation with histological diagnosis.The imaging techniques guide in preoperative diagnosis and management of patients with an unidentified cardiac mass. Tissue characterization through multimodality imaging may provide an excellent correlation to the pathological diagnosis of a mass.


Synovial sarcomas represent a highly malignant form of mesenchymal tumors. The incidence of synovial sarcomas in the spinal canal is exceptionally rare and has been scarcely reported.Comprehending the magnetic resonance imaging manifestations of intraspinal synovial sarcoma is important to prevent misdiagnosis. Synovial sarcoma (SS) is an infrequent, highly malignant mesenchymal tumor, accounting for approximately 5–10% of all soft tissue sarcomas . IntraspA 65-year-old woman presented with persistent pain in the right posterolateral lumbosacral region and right lower limb for over a year. The pain was accompanied by continuous burning sensations, fatigue in the right lower limb, and difficulty in walking. However, there were no reports of dizziness, headache, incontinence, or other symptoms. Upon physical examination, grade IV muscle strength was observed in both lower limbs. Warm tactile sensation was absent in the right posterolateral lumbosacral region and could not be perceived above the posterolateral knee of the right lower limb or below the waist. The bilateral Babinski and Hoffman signs were negative. Laboratory examinations yielded no abnormalities. The patient had no significant prior medical history or family history and no evidence of neurofibromatosis.MRI revealed a strip-like mass in the spinal canal at the level of L4-S2, measuring 6.5 cm × 1.6 cm in size. The mass exhibited an isosignal on T1WI , and exhThe patient underwent intraspinal resection, and during the operation, the lesions exhibited a fish-like appearance, with an abundant blood supply. The lesions closely adhered to the peripheral nerve root, with high dural tension, necessitating the cutting of the dura mater, resulting in the tumor gushing out. Postoperatively, fusiform tumor cells when observed under a light microscope. Immunohistochemistry results were as follows: CK (-), Syn (-), ki-67 , TLE-1 (+), H3k27me3 (+), and S-100 (+); FISH test: SS18-SSX  , suggestThe occurrence of primary SS in the spinal canal is exceedingly rare. The imaging findings of intraspinal SS lack distinct specificity. However, MRI plays a crucial role in depicting the tumor’s location, its relationship with surrounding structures, and assessing pathological changes. Typically, MRI manifestations of intraspinal SS exhibit equal or slightly lower signal intensity on T1WI, with focal high signal intensity due to hemorrhage and predominantly high signal intensity on T2WI. Approximately 33% of tumors display typical triple signals, characterized by a mixture of high, equal, and low signal intensities . ComputePrimary intraspinal synovial sarcoma is a rare malignant tumor with atypical radiological manifestations. On the basis of the imaging features, it is not possible to differentiate a synovial sarcoma from a malignant peripheral nerve sheath tumor, but the degree of extension of the intradural tumor along the peripheral nerve sheaths should raise the suspicion of a sarcoma.


Gastric subepithelial tumors (SETs) are often incidentally found during examinations of the gastrointestinal tract. Able to arise from any layer of the stomach, these tumors are predominantly asymptomatic and are classified as either benign or malignant based on size, consistency, shape, and mobility as determined by endoscopic evaluation. We present the first reported case of a gastric SET presenting as a chronic organizing hematoma. In doing so, we discuss the necessity of multimodal imaging techniques and multidisciplinary management in identifying often obscure gastric SETs to intervene on potentially malignant masses early. Characterized by location, size, and echogenicity, the gold standard of diagnosis for SETs is histology and immunohistochemistry, usually performed with fine needle aspiration. There is a spectrum of imaging modalities to diagnose SETs with 2 major ones being esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS). EGD is suboptimal in differentiating intraluminal lesions from extraluminal SETs with a sensitivity and specificity of 87% and 29%, respectively. By contrast, EUS is the most accurate method for differentiating SET location. They are operator-dependent, but, in the right hands, EUS approaches a sensitivity of 92% and a specificity of 100%. Despite this, some cases require other modalities to make a definitive diagnosis.A 64-year-old woman presented with emesis and worsening epigastric pain for 24 hours. Medical history included uncontrolled type 2 diabetes, stage 4 chronic kidney disease, and a hiatal hernia. 30 years ago, she underwent an exploratory laparotomy with splenectomy for multiple abdominal gunshot wounds and a hysterectomy with bilateral salpingo-oophorectomy for fibroid tumors. Computed tomography (CT) of the abdomen/pelvis without contrast showed a large 12-cm mesenteric neoplasm arising from the transverse mesocolon without evidence of obstruction (Figure Notably, a CT of the chest from 4 years earlier captured the upper abdomen, which did show the mass being present, but no workup was performed for it Figure . EGD shoen bloc resection was performed with an open extended right hemicolectomy and partial gastrectomy with stapled, side-to-side antiperistaltic ileocolonic anastomosis. Postoperative course was unremarkable, and the patient was discharged to a nursing facility on postoperative day 4. Pathology showed an organizing 11-cm hematoma with surrounding fibrosis (Figure She presented to clinic several days later, however, with unrelenting epigastric pain and was immediately sent to the emergency department where a CT showed an increased size of a hyperdense perigastric mass Figure . The pats Figure . Multipl5To the best of our knowledge, this is the first case report regarding an enlarging gastric mass as an organizing intraluminal hematoma. Other cases in the literature have described acute gastric hematomas discovered endoscopically, intraoperatively, or on imaging. Ours was a case of spontaneous intraluminal hematoma associated with previous abdominal trauma and surgeries. Our patient presentation was different to other cases in the literature, and the identification of a hematoma was not as clear. Our working diagnosis was a tumor as the mass was seen 4 years earlier on another CT. Our imaging in this patient was indeterminate. The mass seemed to have some features of a hematoma but was concurrently noted to have no hyperintense T2 signal and absent calcification, both of which are classic imaging findings of chronic hematoma formation. Her repeat noncontrast CT, however, showed a hyperintense perigastric mass, an imaging finding that can be seen with hemorrhage but also with hypercellular neoplastic processes. The location at the greater curvature of the stomach and its continual increase in size, however, favored a neoplastic formation. It is also important to note that postcontrast subtraction imaging on magnetic resonance imaging was not performed. If this had been performed, one could have confirmed if the mass is intrinsically hyperintense from hemorrhage or protein content or a hypovascular mass with little enhancement. Pathology, however, was more definitive in the diagnosis of hematoma formation, considering the patient's medical history and recent trauma. The negative staining for CD117, CD34, and discovered on GIST-1 protein rules out gastrointestinal stromal tumor, Negative beta-catenin staining eliminates fibromatosis and negative ALK staining eliminates inflammatory myofibroblastic tumor as possible diagnoses. The positive smooth muscle action and desmin stains favor myofibroblastic cells and suggest a non-neoplastic process, and the overall pathology findings are consistent with fibrosis surrounding an organizing hematoma. The mass was indeed examined intraoperatively too. Further discussion as to the cause and possibility of malignancy associated with the chronicity of the mass was held until final pathology returned. gastrointestinal stromal tumor was not confirmed on staining, so succinate dehydrogenase testing was not performed. It is our theory that the patient's remote history of an exploratory laparotomy and splenectomy may have played a role in the initial development of a hematoma that never fully resorbed. She was not on any anticoagulation. Therefore, a slow growth, rather than an acute herald bleed, could be explained by our patient's other medical comorbidities precluding adequate healing of the hematoma. It is important to use multiple diagnostic tools to help guide operative intervention for subepithelial gastric masses with surgery being the best definitive treatment option in symptomatic patients.Author contributions: CJ Miranda, W. Schertzing, A. Shah, and PAR Del Prado compiled a literature review and wrote the manuscript. CJ Miranda is the article guarantor.Financial disclosure: None to report.Previous presentation: This case was presented at the American College of Gastroenterology; October 23, 2022; Charlotte, NC; and received an Outstanding Poster Presenter Award.Informed consent was obtained for this case report.


Neonatal hydrometrocolpos (HMC) is a cystic dilatation of a neonate's vagina and uterus occurring secondary to congenital vaginal obstruction, with or without maternal estrogenic stimulation of uterine and cervical glands causing increased secretions during the prenatal and postnatal period. Diagnosis is made using ultrasonography and further confirmed by MRI. HMC in a neonate can rarely present with congenital anomalies such as polydactyly, which may indicate a variety of underlying genetic syndromes. There is a deficit in the literature as to whether the development of HMC in a neonate of consanguineous parents is an isolated finding or solely related to an underlying syndrome. We hope to help bridge this gap by reporting a case of a 12-day-old neonate presenting with hydrometrocolpos and polydactyly, born to consanguineous parents. Neonatal hydrometrocolpos (HMC) is a cystic dilatation of the vagina and uterus occurring secondary to congenital vaginal obstruction. Most cases occur due to imperforate hymen, but other embryological pathologies such as vaginal atresia, transverse vaginal septum, and cloacal malformations can also lead to its development. Maternal estrogenic stimulation of uterine and cervical glands causing increased secretions during the prenatal and postnatal period has been shown to play a role . OverallWe present a 12-day-old baby girl, born preterm at 36 weeks of gestation, to a gravida 6, para 2, aborta 3 mother. Parental history was positive for consanguinity. Antenatal ultrasound revealed marked abdominal distention with bilateral hydronephrosis. She was born via spontaneous vaginal delivery with a cephalic presentation at a local hospital in northern Saudi Arabia. APGAR scores were eight and nine at one and five minutes, respectively. The growth parameters identified a birth weight of 2.5 kg, head circumference of 32 cm, and body length of 47 cm. The baby was referred to as a case of a huge pelvic cystic mass for advanced care at the neonatology department.Upon physical examination, the patient was vitally stable on room air with good activity and a pinkish appearance. She was able to tolerate oral food and had no signs of jaundice or dehydration. Normal eyes and ears, bilateral patent nose, and no evidence of cleft lip or palate were noted. Upper limbs were normal; however, an examination of the lower limb showed an extra digit in the right foot. Marked abdominal distension was appreciated, with a palpable mass extending from the suprapubic region to the epigastrium. Examination of the genitalia was positive for one common orifice for both the vagina and urethra. The patient had passed urine and stool upon admission. Nervous, cardiac, and respiratory examinations were otherwise insignificant.Initial lab investigations revealed several abnormalities  with the involvement of the following teams: pediatric surgery, pediatric urology, nephrology, genetics, and ophthalmology. She was maintained on incremental doses of oral feeding with IV fluids. Repeat blood tests showed irregularities in creatinine and potassium with values of 3.6 mg/dl (0.57-1.11) and 6.1 mmol/L (3.7-5.9), respectively. Decisions involving an urgent need for possible cystoscopy, vaginoscopy, midline laparotomy, vaginostomy, vaginoplasty, and vaginal pull-through were made by pediatric surgery and pediatric urology.Hydrometrocolpos (HMC) is a rare malformation causing distention of the uterus and vagina due to the accumulation of secretions. These secreted products can either be urine or uterine mucus stimulated under the influence of maternal estrogen. A diagnosis of HMC is made when there is a vaginal outlet obstruction, such as imperforate hymen, vaginal atresia, etc., causing the buildup of secretions . DependiUltrasound is the most widely used tool for diagnosing HMC, which normally reveals a cystic pelvic mass. MRI or CT scans can be used for definitive diagnosis in case of inconclusive results, the former being used in our case . HMC is HMC can be an isolated finding or, more commonly, associated with congenital anomalies such as polydactyly, as in our patient. This association is found in many syndromes, including MKS, BBS, and EVC. The presence of consanguinity in our patient's parents should be considered due to its association with autosomal recessive disorders. A study done in 2021 found the rate of consanguinity in Saudi Arabia to be 52%, 39.3% of which were first-cousin marriages . AnotherThe limitation of our case is the inability to perform molecular testing to confirm a possible underlying congenital syndrome despite having HMC in association with polydactyly. MKS, for instance, presents with cardiac anomalies; however, even with a confirmed cardiac defect on imaging, genetic analysis is required for diagnosis (chromosome 20p12 between D20S162 and D20S894 markers) . SimilarHMC is a rare malformation that presents with an abdominopelvic cystic mass secondary to vaginal outlet obstruction. Diagnosis can be made pre- or postnatally using appropriate radiological modalities. One should have a high index of suspicion to allow immediate diagnosis and management to prevent any associated complications. There is a deficit in the literature as to whether the development of HMC in a neonate of consanguineous parents is an isolated finding or solely related to an underlying syndrome. Our case further elucidates the importance of bridging this gap to help with future in-depth studies.


Obturator hernia (OH) is a rare external abdominal hernia, accounting for only 0.07%–1% of all hernia cases. Because the female pelvis is wider and there is less preperitoneal adipose tissue, the obturator canal is larger, which can lead to herniation of abdominal contents when abdominal pressure increases in elderly women with thin body. The clinical symptoms of patients with obturator hernia included abdominal pain, nausea, vomiting, etc., and the mass in the inguinal region could not be touched. The positive Howship-Romberg sign is a specific sign of OH. CT is the first choice for the diagnosis of obturator hernia. Since intestinal incarceration in OH patients is prone to lead to intestinal necrosis, emergency surgical treatment is often required. However, due to the lack of specificity of its clinical manifestations, the misdiagnosis rate is high, which often leads to the delay of diagnosis and treatment.We report the case of an 86-year-old woman with a thin body and a history of multiple deliveries. The patient presented with abdominal pain, bloating, and constipation for 5 days. Physical examination revealed a positive Howship-Romberg sign on the right side, and CT examination suggested intestinal obstruction. Therefore, an urgent exploratory laparotomy was performed.After opening the abdominal cavity we found that the wall of the ileum was embedded in the right obturator, and the proximal bowel was significantly dilated. We restored the embedded bowel wall to its original position, resected the necrotic bowel and performed an end-to-end anastomosis of the small intestine. The right hernia orifice was sutured, and OH was diagnosed during the operation.This article summarizes the diagnosis and treatment of OH by sharing this case, so as to provide a more detailed plan for early diagnosis and treatment of OH. It was first reported by de Ronsil in 1724. OH has a relatively low incidence, accounting for only 0.07%–1% of all hernias. It is most common in thin elderly women. The incidence rate in women is 6–9 times higher than in men . A patie2.2.1.The patient was an 86-year-old woman admitted to hospital because of abdominal pain and abdominal distension with constipation for 5 days. The patient developed abdominal pain and flatulence after eating 5 days previously, accompanied by nausea, vomiting (once) of food and bile, and constipation, without acid reflux, belching, frequent urination, urgency, dysuria, shivering or fever. However, the abdominal distension persisted, so the patient went to the local hospital. After an abdominal computed tomography (CT) scan and various other examinations, intestinal obstruction and double lung inflammation were considered, and she was treated with gastrointestinal decompression, somatostatin (to inhibit the secretion of digestive fluid), and rehydration (for which the specific medication and dosage are unknown) for 4 days. However, the abdominal distension did not improve significantly, so she was transferred to our hospital for treatment. The abdominal standing plain x-ray film showed gas shadows and the gas-fluid levels in the intestine, but there was no free gas under the diaphragm . The patWhen the patient is instructed to straighten the legs and rotate them outward, pain occurs in the right inner thigh with a sense of soreness.2.2.9/L; no other results were abnormal. CT enhancement of the entire abdomen and pelvis showed that the intestines in the left abdomen and pelvic cavity areas were “aggregated”. The small intestinal wall on the right side of the pelvic cavity was thickened, with mild and uneven enhancement. Some of the intestines in the upper segment were dilated, while others showed an accumulation of gas and effusion, and some were flat. The sigmoid colon was long. Dense shadows were seen in the abdominal and pelvic cavities. A convex shadow was seen in the right inguinal area of the intestinal canal, and the corresponding intestinal wall was thickened. This finding was consistent with a small intestinal obstruction or OH  was absorbed and further exploration showed that the ileal wall was incarcerated at the right obturator 70 cm from the ileocecum. Moreover, the proximal intestine was dilated, the intestinal wall was congested and edematous, the distal intestine was empty, and there were no obvious abnormalities in the intestinal wall. When the incarcerated intestinal wall was returned to its original position, a 3-cm-diameter section of ischemic necrotic tissue was detected . Continu2.4.Antibiotic therapy and rehydration were provided after the operation, and no obvious abnormalities were detected by postoperative CT . The pat3.The obturator foramen, located on the anterolateral side of the pelvic wall, directly below the acetabulum, is the largest foramen in the human body. At embryonic week 8, the hip osteondral primordium is obvious, forming an incomplete obturator foramen, obturator membrane, and nerve vascular bundle . The iscBecause of the deep location, small hernia ring, and difficult-to-reach surface, the clinical manifestations of OH are not specific, and the misdiagnosis rate is high before the operation: the incidence of OH is low, such that it is rarely encountered; the patients are elderly women with other diseases, poor general condition, a high pain threshold, atypical symptoms and signs, and symptoms that are easily masked; and the patient's family may prefer conservative treatment and visit other departments, such as gastroenterology and pain departments. Diffuse peritonitis caused by intestinal perforation and intestinal necrosis, as well as septic shock, may develop. The incidence and mortality rates of septic shock are both 70% . Our patThe clinical manifestations of OH are abdominal pain caused by intestinal obstruction and obturator neuralgia (Howship-Romberg sign) caused by compression of the obturator nerve. More than 70% of patients have an acute intestinal obstruction of unknown etiology. In the initial stage, due to the shallow bottom of the hernia sac, the hernia content is easy to “reset,” and recurrent abdominal pain may develop . When anCT is the first choice imaging modality for preoperative diagnosis of OH, given its diagnostic accuracy and specificity of 78%–100% . A circuOH should be treated as early as possible after diagnosis, to reduce the likelihood of complications such as intestinal necrosis, intestinal perforation, peritonitis, and septic shock. The main surgical methods are laparotomy and laparoscopy. Exploratory laparotomy causes trauma, and patients are predominantly females with various diseases. Postoperative complications, such as poor wound healing and pulmonary infection, easily occur. Endoscopic surgery has the advantages of less trauma and postoperative pain, and rapid recovery of digestive tract function. Many studies have focused on the application of endoscopic surgery for OH . HoweverA lower abdominal exploratory incision is the preferred surgical approach, because this allows for comprehensive and systematic abdominal exploration. An exploratory laparotomy allows for deep exploration to determine whether there is an occult hernia, femoral or inguinal hernia, and/or small intestinal diverticulum . The ope4.Obturator hernia is very rare and difficult to diagnose. When elderly women with long-term chronic diseases, a thin body, or a history of multiple deliveries have the following conditions: (1). Symptoms of intestinal obstruction (2). Sudden abdominal pain due to increased intra-abdominal pressure (3). Pain in the inner thigh and mild abdominal distention only. All patients should be alert to OH. Howship-Romberg sign should be checked during physical examination. If there is a palpable mass in the inguinal region, it should be differentiated from indirect inguinal hernia and direct inguinal hernia. Abdominal CT is the first choice for imaging examination. Once diagnosed, early surgery should be performed to relieve obstruction and repair defects . Timely