Schwannoma can rarely mimic an intraneural ganglion cyst clinically and radiographically. This is a rare case report of a wrist schwannoma mimicking an intraneural ganglion cyst. The surgery was successful, and the histopathological report confirmed the diagnosis of benign schwannoma. After two years of follow-up, the patient is still symptom-free. Schwannoma is the most benign peripheral nerve tumor originating from Schwann cells of the nerve sheath. Schwannomas are usually isolated, solitary, slow-growing, and encapsulated neoplasms composed totally of Schwann cells of myelin sheaths. Although they can occur at any age and in any part of the body, they most commonly tend to occur between the third and sixth decades of age and appear in the head and neck areas of the body. Also, there is no sex predisposition that appears to exist for the occurrence of these tumors ,2. In clA 43-year-old male patient, with no significant medical or surgical history, presented to the clinic with two painful lesions located on the dorsum of his right wrist. The patient first noticed these lesions three years ago, and they have been a source of persistent pain and discomfort. The patient reported occasional hand pain, but denied any numbness, tingling, functional impairment, or weakness. There was no history of trauma, infection, or constitutional symptoms. A thorough review of the patient’s medical history did not reveal any notable findings, and there was no family history of neurofibromatosis or similar conditions.Upon examination, two painful subcutaneous palpable lesions were identified on the dorsum of the right wrist. These lesions exhibited an oval shape and demonstrated non-mobility, non-pulsation, and soft consistency. Each lesion measured less than 10 mm in size and appeared nearly identical in dimensions.Tinel’s and Phalen’s signs were negative. All motor and sensory examinations of the hand were normal. To diagnose the lesions, he underwent both hand ultrasound and MRI, and the radiological characteristics were consistent with cystic lesions .During the ultrasound examination, the two lesions exhibited distinct morphological and structural characteristics. The ultrasound findings revealed that both lesions appeared as cystic structures. They exhibited well-defined boundaries and were ovoid in shape. The lesions were located laterally to the extensor carpi radialis tendon. The MRI without contrast report showed two separate, well-defined ovoid structures located laterally to the extensor carpi radialis tendon. The largest of these structures measured 6 × 5 mm and communicated with the underlying joint space, consistent with a ganglion cyst. A preoperative diagnosis of two intraneural ganglion cysts was made, and after discussing treatment options, he was scheduled for elective surgery to remove the lesions. In the operating room, when the skin was cut open, and the lesions were first exposed, they exhibited a gross appearance that was more consistent with Schwannoma tumors, with no cystic material emerging on aspiration . Both leThis is a rare case report of a benign wrist schwannoma tumor that was initially misdiagnosed by its clinical presentation and MRI features as an intraneural ganglion cyst.The literature review revealed ten similar case reports of upper-extremity schwannomas that were initially misdiagnosed as ganglion cysts  4–12]..4–12].This study employed a narrative research strategy to identify relevant articles for inclusion in the literature review. The search was conducted using two databases, including PubMed and Google Scholar. The search terms used were ‘schwannoma’, ‘intraneural ganglion cyst’, ‘wrist’, and ‘mimic’. The inclusion criteria for article selection were as follows: (1) Articles published in English language, (2) Case reports or case series describing a wrist schwannoma mimicking an intraneural ganglion cyst, (3) Detailed clinical and radiographic presentation, (4) Surgical intervention and histopathological confirmation of the diagnosis, (5) Adequate follow-up to assess patient outcomes. The exclusion criteria were: (1) Articles not directly related to the specific case of wrist schwannoma mimicking an intraneural ganglion cyst, (2) Articles lacking essential clinical or radiographic information, (3) Studies with incomplete or insufficient follow-up data.The enrolled patients’ ages ranged from 22 to 70 years old, and out of the 10 cases, 7 were females. The presenting symptoms were pain, paresthesia, and/or weakness, and mostly, the symptoms were chronic in nature. No specific patterns were noticed in the tumors’ locations, as they can present anywhere along the nerves’ courses. Preoperative ultrasound and/or MRI were done in 9 out of 10 cases, and they all were consistent with ganglion cysts . The posIntraneural ganglion cysts are defined as mucinous non-neoplastic cysts within the epineurium of a nerve and commences from an adjoining joint. Their clinical presentation and radiological features can mimic schwannomas, specifically when it is affecting the wrists or the knees [Schwannomas, as mentioned earlier, are the most common benign peripheral nerve tumors. However, their occurrence in the upper extremities is rare compared to other neoplasms . They grhe knees ,13. Howehe knees ,13.This study highlights and re-emphasizes the importance of keeping benign schwannoma as a differential diagnosis of upper extremity radiologically cystic-appearing lesions. This study, as mentioned, is a case report and literature review, which may impact the reliability and the strength of evidence of the data. A larger retrospective study focusing on the differentiation of both lesions are recommended.Schwannoma and intraneural ganglion cyst can present in a clinically and radiologically similar manner. As a result, maintaining a differential diagnosis of both lesions and carefully planning surgical management is essential. The prognosis of both lesions is generally favorable. Surgeons and radiologists should collaborate in the preoperative diagnosis to minimize misdiagnosis rates and associated complications. Although schwannoma mimicking intraneural ganglion cysts is a rare presentation that poses a significant diagnostic challenge, clinicians should maintain a high index of suspicion and thoroughly evaluate all diagnostic data to avoid misdiagnosis and ensure proper treatment. Increased awareness of this entity may result in a more timely diagnosis, better patient outcomes, and an improved quality of life.


Knowledge about normal and pathological anatomical variants is a key point for all surgeons to perform safe procedures and manage unexpected findings. One example of this is vascular anomalies involving the celiac and superior mesenteric arteries (CA and SMA) and their anastomoses. During a routine workup of a suspected calcified pancreatic lesion, an asymptomatic arc of Buhler was found, connecting the CA and SMA, with 90% stenosis of the celiac trunk. This embryological variant, despite being a rare occurrence, has significance in various surgical procedures, including pancreatoduodenectomy, liver transplantation and interventional radiological procedures, such as gastroduodenal artery ligation and embolisation. The arc of Buhler is an embryological remnant of the ventral anastomosis, connecting the otherwise separated celiac and superior mesenteric arteries (CA and SMA) despite the regression of the 11th and 12th vitelline arteries. During embryogenesis, there are four omphalomesenteric arteries, 10th–13th, allowing communication between the aorta and the primitive ventral anastomotic artery. This is because of the initial dual blood supply to the abdominal viscera via dorsal and ventral arteries. During normal development, the CA arises from the 10th, the SMA from the 13th vitelline artery, whereas the 11th and 12th regress [The CA, together with the SMA and the inferior mesenteric artery, is the major blood supply to the abdominal viscera. There are well-known anastomoses between these major arteries. The two main connections between the CA and the SMA are the gastroduodenal and a dorsal pancreatic artery. In rare cases, such as described below, there is a third connection, the Buhler’s arc .A 77-year-old female presented with sudden onset of pleuritic chest pain. Initial investigations showed no ECG changes, normal chest X-ray and normal troponin level. Blood tests were normal. D-Dimer was elevated. Her background history included gastro-oesophageal reflux disease, asthma, chronic kidney disease, polymyalgia rheumatica and anxiety. She had a previous non-provoked PE and completed 6 months of treatment with Rivaroxaban. Her previous thrombophilia screen was negative. CT pulmonary angiogram showed multiple bilateral segmental and subsegmental pulmonary emboli with associated lingular haemorrhage. She was initially treated with Heparin infusion, which was changed to Rivaroxaban. As this episode was her second unprovoked PE without any identified precipitating factors, including immobility, recent major surgery or long-haul travel, it was decided to investigate the possibility of underlying malignant processes.CT of abdomen and pelvis was performed, which revealed a 13 mm indeterminate lesion arising between the pancreatic uncinate process and the duodenum with coarse peripheral calcification, suspicious of primary pancreatic neoplasm or primary small bowel cancer –4.All specific tumour markers were normal.She has not had recent abdominal pain, jaundice or weight loss and she had a good appetite. She reported no changes in her bowel habits. There was no history of pancreatitis, or a family history of pancreatic or other malignancies. Ex-smoker with 25 pack year history having quit 38 years ago and social drinker. She had a laparotomy for perforated appendicitis 50 years ago.A multiphase CT of the pancreas had unexpected findings. There were no pancreatic masses on the arterial and portal phase study, and no paraaortic or mesenteric lymphadenopathy. The abnormal calcification seen on the previous study corresponded to a dilated vessel along the superior margin of the pancreatic body. This dilated vessel was an abnormal communication between a tortuous ecstatic gastroduodenal artery and the first branch of the SMA, a Buhler’s arc communication. The celiac axis origin was narrowed >90%. No other suspicious solid organ mass lesion was identified. Soft tissues were unremarkable –8.The patient was discharged on day three post-admission and currently waiting for a vascular surgical review.et al. [et al. [et al. [et al. [The rare, third anastomosis between the CA and SMA named after Buhler who first described it in 1904 . The theet al. , 1.7% in [et al. , 3.3% of [et al. .Most of the cases were incidental findings on appropriate images of asymptomatic patients, such as our case. There are case reports of ruptured aneurysm of the arc of Buhler causing median arcuate ligament syndrome, fatal retroperitoneal bleed or obstructive jaundice. There is an important association of the existence of the Buhler’s arc in planning of pancreatoduodenectomy in a case of CA stenosis, especially with ligation of the gastroduodenal artery , 10.Awareness of this anatomical variation is also crucial in interventional radiological procedures, such as gastroduodenal artery ligation and embolization of various aneurysms of the gastrointestinal vascular system.In our case, it was an unexpected, incidental finding of the arc of Buhler during a routine workup for a calcified pancreatic lesion. The patient was asymptomatic, despite a 90% stenosis of the celiac origin because of the collateral blood supply from the SMA via the arc of Buhler.This case highlights the importance of choosing the appropriate imaging for a pancreatic lesion workup, especially if biopsy is being considered. Additionally, it emphasises the significance of the knowledge of embryological development and vascular variations of the mesenteric blood supply.None declared.None.All data and materials can be found in the article. No other data or materials were used.Informed consent was obtained from the patient for publication of this case report and accompanying figures.


Meigs’ syndrome is defined as a secondary triad of ascites, pleural effusion and benign ovarian tumor, usually fibroma. While pseudo-Meigs’ syndrome is a rare condition that is associated with benign ovarian tumor—other than fibroma—or even malignant. The case presented is a 40-year-old Saudi, nulliparous woman who was referred for precise diagnostic work-up as a case of huge pelvic-abdominal mass, tense ascites and pleural effusion. After further investigations cancer antigen-125 was found to be elevated. An abdominal CT scan revealed significant interval increase in the size of ascites, which cause huge abdominal distention, as well as a significant pleural effusion. Pathology of surgical specimens revealed a giant uterine leiomyoma, whereas the omentum excision surprisingly confirmed multiple disorganized arteries and veins, which resulted in omental arteriovenous malformation. To the best of our knowledge, this is the first reported case in the worldwide literature of two different rare conditions. Meigs’ syndrome is a rare medical condition that is characterized by the presence of a benign ovarian tumor usually a fibroma, in combination with accumulation of fluid in the abdomen called ascites and the buildup of fluid in the pleural cavity called pleural effusion . Pseudo-A 40-year-old Saudi, nulliparous woman, medically free with a history of leiomyoma (uterine fibroid) underwent myomectomy. She was referred to our center as a case of large abdominopelvic mass, tense ascites and pleural effusion. The patient complained of the shortness of breath, palpitation, marked abdominal discomfort and bloating as well as back pain. She reported that she first noticed the bloating 3 months prior to the visit. However, she was unable to come because of COVID-19 pandemic situation. She is a housewife; never smoked tobacco or drank alcohol, and had no history of recent travel to endemic or pandemic areas. On further investigations, a serum CA-125 was found to be elevated 492.6 U/mL , whereas the concentration of other tumor markers LDH, CEA, CA19-9 and ALP was within normal ranges. Abdominal CT scan revealed a significant interval increase in the size of ascites, which caused a huge abdominal distention along with severe mass effects on the abdominopelvic organs, which have been displaced posteriorly as shown in Omental lesions have a difficult preoperative diagnosis and the diagnosis is often made postoperatively. Accurate diagnosis is made through the histopathological examination of the lesion . In our Omental AVM is an extremely rare lesion that could have significant presentation. A high index of suspicion for pseudo-Meigs’ syndrome should be entertained in women presenting with abdominopelvic mass, ascites and pleural effusion with benign clinical features especially for those with previous history of uterine fibroids. This case report raises questions for further discourse and research on the omental AVM and its association with pseudo-Meigs’ syndrome.


This case report of an infant details a rare occurrence of a cecal duplication cyst causing bowel obstruction. It was successfully treated through an extra mucosal enucleation. The patient presented at 41 days of life, with two days picture of abdominal distension and recurrent non-bilious vomiting. The infant improved initially, but subsequently, he developed bilious vomiting. Further investigations revealed a suspected ileocolic intussusception and small bowel obstruction. Surgical exploration revealed a cecal duplication cyst. The cyst was enucleated, and closure of the seromuscular defect was done with an appendectomy. The patient had a smooth recovery postoperatively. Histopathology confirmed the presence of a duplication cyst with benign ectopic gastric tissue negative for malignancy. The patient was discharged without any complications. Cecal duplication cysts (CDCs) are an uncommon congenital abnormality of the gastrointestinal tract that can result in intestinal obstruction . These eAccording to estimates, CDCs account for a mere 0.4% of all gastrointestinal duplications . TypicalThe clinical manifestations of duplication cysts exhibit a significant degree of variability, contingent upon the specific type, size, and location of the lesion. Generally, symptoms arise within the first two years of life, prompting the necessity for radiological assessment to facilitate an accurate diagnosis . These sIn this article, our objective is to present a case study of an infrequent occurrence: a duplication cyst in the cecum. The management of this particular case involved a surgical procedure known as enucleation, which yielded favorable results without any complications. Additionally, we encountered a diagnostic dilemma, highlighting the importance of raising awareness within the healthcare community when faced with similar cases.This is a case of a 41-day-old infant boy with no known medical conditions. The mother had an uneventful antenatal period. The baby had regular prenatal check-ups and passed meconium within the first 24 hours. The baby was brought to the emergency department with a history of repeated vomiting, which later turned into bilious over the past two days. The infant had mild abdominal distension and regular bowel movements. There were no other significant symptoms. An abdominal X-ray Figure . The babDuring the procedure, a duplication cyst was discovered at the lateral outer part of the cecum. The cyst was aspirated, yielding 3-5 ml of pale yellow to clear fluid, which was sent for cytology analysis Figure . The cytThe diagnosis of CDC is often challenging due to its presentation as unrelated and atypical symptoms. To differentiate it from intussusception, imaging studies such as abdominal ultrasound or CT are necessary for confirmation. For example, the presence of a hyperechoic wall or a double wall sign on an ultrasound can help identify the cysts. While ultrasonogram is the most commonly used imaging modality for duplication cysts, MRI or CT scans may also be utilized to confirm the diagnosis . TherefoResection and anastomosis is the preferred treatment for CDCs, and this procedure has a generally positive outlook . In instOur patient underwent surgical extra mucosal enucleation of the cyst, without mucosal perforation. This approach has been documented in the literature, and other surgical techniques and interventions at the lesion site have also been reported.Early identification is crucial in preventing complications associated with duplication cysts, including perforation, intussusception, volvulus, and malignancy . HoweverOur case presents a distinct instance of distal intestinal obstruction resulting from a duplication cyst in the cecum. This case serves as a reminder of the significance of thorough clinical examination and imaging techniques in accurately diagnosing this uncommon condition. Surgical removal is considered the most dependable course of action for CDCs and should be undertaken with the aim of preserving the integrity of the cecal wall, if feasible. Based on the existing evidence, the excision of duplication cysts in children is a secure and efficient treatment option. The surgical approach should be customized to the specific patient and the location of the cyst. Whenever possible, complete removal is advised.


Solitary extramedullary plasmacytomas are an exceedingly rare form of malignant neoplasms characterized by a single localized mass located in any soft tissue that consists of abnormal plasma cells. This type of tumor is characterized by the absence of plasmacytosis on bone marrow biopsy, the absence of other lesions on imaging, and no clinical signs of multiple myeloma. They usually present with mass effect, so the clinical picture varies based on the location of the tumor. In cases where the tumor is located in the gastrointestinal tract, patients may experience abdominal pain, small bowel obstruction, or gastrointestinal bleeding. The diagnostic process typically involves imaging to identify the tumor and its location, followed by a biopsy of the lesion with subsequent immunohistochemical analysis, as well as fluorescence in situ hybridization, and finally, bone marrow biopsy. Treatment options vary depending on the tumor's location and may include radiation therapy, surgical resection, and chemotherapy. Currently, radiation therapy is the preferred first-line treatment, with the best outcomes reported in the literature. Surgery is also frequently used and is often followed by radiation therapy. While chemotherapy has not been shown to have significant benefits, the available data is insufficient, and further studies are required to make better conclusions. Disease progression is often associated with transformation to multiple myeloma, but due to the rarity of the disease, data is limited, and it remains unclear if other forms of progression exist. We report a case of a 63-year-old male who presented to the hospital with symptoms of abdominal pain, nausea, and vomiting. A computed tomography scan revealed a mass causing bowel obstruction, which was subsequently resected and evaluated by pathology. The final diagnosis was determined to be a solitary extramedullary plasmacytoma. Since the margins of the resected mass were clear, the patient was managed with solely clinical observation. Approximately eight months later, the patient was diagnosed with T-cell anaplastic large-cell lymphoma, ultimately leading to his passing 15 months after the initial diagnosis of solitary extramedullary plasmacytoma. We present this case to increase awareness of the rare condition of solitary extramedullary plasmacytoma and to highlight the potential association with T-cell anaplastic large-cell lymphomas, as demonstrated in this patient's case. Given the possibility of malignant transformation, close monitoring is warranted in similar cases. Solitary extramedullary plasmacytomas (SEP) are plasma cell neoplasms that arise in soft tissues without the involvement of the bone marrow (BM) and lack clinical signs of multiple myeloma (MM) . They ocWe present a case of a 63-year-old male with abdominal pain and small bowel obstruction who was ultimately diagnosed with SEP of the jejunum. Our aim is to increase awareness of this rare condition, share our experience in managing this patient, and highlight a potential variant of progression that has not been previously reported, the development of T-cell anaplastic large-cell lymphoma.The patient is a 63-year-old male who presented to the emergency department (ED) with intermittent, colicky abdominal pain in the right lower quadrant associated with nausea, non-bloody vomiting, and an inability to pass stool or gas for about 48 hours. The patient denied blood in his stool or any other symptoms. Upon examination in the ED, the patient's vital signs were normal, and a physical exam revealed tenderness to palpation in the right lower quadrant of the abdomen. Lab results showed mild leukocytosis, but other tests were within normal limits, including hemoglobin, platelet, and complete metabolic panel (CMP). A computed tomography (CT) scan of the abdomen and pelvis showed a 2.2 x 4.9 cm heterogeneous mass in the distal ileum with small bowel obstruction and dilated small bowel loops measuring up to 3.3 cm in diameter proximal to the obstruction Figure .The patient was diagnosed with small bowel obstruction secondary to an ileal mass. Given that standard endoscopy could not reach the mass, the decision was made to proceed with an exploratory laparotomy. During the laparotomy, a fist-size mass was identified and removed 3 feet from the ileocecal valve. After the mass was resected, the specimen was sent for histopathologic analysis. Within three days, the patient's symptoms improved; he could tolerate solid food and started having bowel movements. As a result, he was discharged from the hospital. Eventually, the surgical pathology report showed an 8.5 cm tumor involving the full thickness of the bowel wall from mucosa to the serosa with vast areas of necrosis, acute inflammation, and abscess formation Figure . The tumThe absence of anemia, hypercalcemia, renal dysfunction, or bone pain made MM unlikely as a diagnosis. However, further workup was still recommended to establish the diagnosis of SEP. The workup included serum and urine protein electrophoresis with immunofixation, serum kappa and lambda free light chain (FLC) measurement, and BM biopsy.No monoclonal protein was detected in the serum or 24-hour urine protein electrophoresis. Analysis for free kappa and lambda light chains was unremarkable. He also underwent an 18-Fluorodeoxyglucose positron emission tomography (FDG-PET) scan, which was unremarkable with no pathologic findings. BM biopsy showed normocellular marrow with trilineage hematopoiesis with no morphologic, immunohistochemical, or flow cytometric evidence of plasma cell neoplasm involvement. MM panel by FISH of the BM sample showed normal results with no evidence of gain of CKS1B at 1q, t, t, t, t, gain of chromosome 9 or 11, or TP53 deletion. The final diagnosis of SEP was established, and the patient's case was reviewed during a tumor board conference. Based on the clear resection margins and lack of lymph node involvement, the consensus was not to offer adjuvant therapy and to proceed with surveillance with repeat serum and urine protein electrophoresis with immunofixation, kappa and lambda FLC measurement, complete blood count, CMP, and CT of the chest, abdomen, and pelvis in 6 months. Approximately eight months after the diagnosis of SEP, the patient started experiencing left leg pain. A magnetic resonance imaging (MRI) of the left tibia and fibula was performed, which showed a large centrally necrotic intramuscular mass in the tibialis anterior muscle Figure . The masSolitary plasmacytomas (SP) are single localized neoplasms consisting of monoclonal plasma cells characterized by the absence of bone marrow plasmacytosis. Based on their location, they can be categorized into two types: solitary bone plasmacytomas (SBP), which are tumors involving the bones, and solitary extramedullary plasmacytomas (SEP), which are tumors that arise in soft tissues . SP is fSP is a very rare condition, occurring at a rate of only 0.34 per 100,000 people per year. The incidences of SEP and SBP are at 0.10 and 0.15 per 100,000 people, respectively . The mosTreatment options for GI SEP are similar to the management of SP in other sites and include radiation therapy, surgical resection, chemotherapy, or a combination of them . ChemothResponse assessment is performed by using the International Myeloma Working Group (IMWG) criteria and Response Evaluation Criteria in Solid Tumors (RECIST), which involves monitoring of serum and urine protein electrophoresis with immunofixation, FLC levels, and serum quantitative immunoglobulins every three months for the first two years, as well as FDG-PET scan at three months after radiation and then every 12 months . As far as we know, there is currently no evidence to suggest an association or shared genetic predisposition between SEP and T-cell anaplastic large-cell lymphoma. However, the genetic abnormalities observed in the two diseases show certain similarities and overlaps, making an association between the two conditions and a transformation from one condition to the other plausible. Therefore, further research is needed to investigate this potential association and shed light on the underlying pathogenic mechanisms. A better understanding of the potential relationship between these two conditions may help improve the management of patients with these diagnoses.Our primary objective is to contribute to the existing literature by presenting the case of a patient diagnosed with SEP who underwent surgical resection without additional radiotherapy or chemotherapy. During the observation stage of management, the patient developed T-cell anaplastic large-cell lymphoma. We recognize the limited data available on the optimal treatment strategies for this rare disease and its association with T-cell anaplastic large-cell lymphoma. Therefore, we hope our case will raise awareness and encourage further investigation to improve our understanding of management options for patients with this condition.


A common mesentery is defined by the persistence of an embryonic anatomical arrangement secondary to an anomaly of rotation of the primary umbilical loop. Caecal volvulus is a rare cause of intestinal obstruction, which account for 1 to 1.5 % of all intestinal obstructions. A combination of both, intestinal mal rotation and caecal volvulus is rare.We report this rare entity in a 50 year old male with no history of abdominal surgery who was admitted for an acute intestinal obstruction. Clinical examination found a non-complicated right inguinal hernia. Radiological assessment showed signs of an incomplete common mesentery and an important small bowl distention with a transitional zone near the profound inguinal ring. Emergency surgery was performed. Surgical exploration didn't find signs of strangulation in the inguinal hernia which motivated midline laparotomy. We discovered a caecal volvulus with an incomplete common mesentery and ischemic lesions in the caecum. Ileocaecal resection was performed with ileocolostomy.Common mesentery can be complete or incomplete. It is often well tolerated in adulthood. This intestinal malrotation can sometimes cause serious complications such as volvulus. Their association is rare. Radiology can be very helpful in leading to the diagnosis, but the diagnostic process should not delay surgical intervention which is the basis of the treatment.Caecal volvulus is a serious complication of intestinal malrotation. This association is rare in adulthood and symptoms are not specific. Emergency surgery is necessary. •The association of caecal volvulus and intestinal malrotation is rare.•CT scan is mandatory for preoperative diagnosis of caecal volvulus.•Emergency Surgery is necessary.•The treatment is based on three elements: reducing torsion, treating possible complications and preventing recurrences. It can be complete or incomplete at a 180°. It is characterized by a persistence of an embryonic anatomical arrangement with a common It is mostly asymptomatic and there for it's estimated prevalence in adulthood is around 0.2 % to 0.5 % [Caecal volvulus is a rare cause of intestinal obstruction, which account for 1 to 1.5 % of all intestinal obstructions. It is defined by an axial torsion of the caecum, ascending colon, and terminal ileum around the mesenteric vascular pedicles . A combiWhile radiology can be very contributive to the diagnostic process, it can sometimes fail to deliver the final diagnosis. Emergency surgery should not be delayed as surgery is the main and most recognized treatment.We report a rare case of a scarce association of a caecal volvulus and an incomplete common mesentery in a 50 year old male.This case report has been reported in line with the SCARE Criteria .2A 50 year old male with chronic kidney disease in the terminal stage receiving hemodialysis and no history of abdominal surgery or bowel disorder was admitted in our surgery department for acute abdominal pain with a rapidly progressive intensity which evolved for 24 h, with nausea, vomiting and abdominal distension. At the initial physical examination, the patient had stable vitals and had no fever, but he was agitated with a poor general condition. The Abdominal examination found a distended tympanic abdomen, with a generalized tenderness, and a large, irreductible but painless right inguinal hernia, which was against the diagnosis of an intestinal obstruction due to a strangled hernia. Rectal examination found an empty rectal bulb. Biology assessment showed a normal white blood cell count but an elevated level of C-Reactive Protein (170 mg/L).After conditioning and reanimation, a radiological assessment was done. Abdominal x-ray showed air-fluid levels. Abdominal CT scan revealed an abnormal position of the duodenojejunal (D-J) flexure which was located to the right of the midline, the third portion of the duodenum was not included in the arterial clamp. The caecum was in the midline in a transverse position, in contact with the anterior abdominal wall with an important distention of small bowel and a transitional zone next to the deep inguinal ring . We deci3Common mesentery results from an abnormality in the rotation of the digestive tract and this insufficient rotation is most often associated with a lack of attachment . The rotAs the persistence of the primary common mesentery in adulthood is often well tolerated and it can rarely be responsible for volvulus, few studies on this acute complication in adults have been reported in the literature, which is why our case is interesting. Clinical manifestations are not specific. The cecum volvulus produces a clinical table of acute intestinal obstruction by strangulation. Abdominal x-ray may show a large hydroaeric level reflecting the distension of the cecum, that could be median, lateralized to the right or to the left , but thaUnlike sigmoid volvulus, endoscopic treatment is not of much interest, with a failure rate exceeding 75 % of cases, but it could be interesting in the case of a contraindication to surgery or in risky areas . The tre4Ceacal volvulus is a serious complication of intestinal malrotation. This association is rare in adulthood and symptoms are not specific. Ct scan is very important to make the preoperative diagnosis. However, it can sometimes mislead surgeons. Emergency surgery should not be delayed, and the surgical technique depends on peroperative findings.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The work has been approved by the ethical committee related to the institution  CHL n°056 on May 8th 2023.No funding was granted.Dorra bel haj yahia: Conceptualization Writing – original draft.Souhaib Atri Writing – original draft.Amine Sebei data curation.Youssef Chaker conceptualization.Houcine Maghrebi supervision.Jameleddine montasser kacem supervision-validation.Dr. Dorra Bel Haj Yahia.None.Dorra Bel Haj Yahia: Conceptualization, Writing – original draft. Souhaib Atri: Writing – original draft. Amine Sebei: Data curation. Youssef Chaker: Conceptualization. Houcine Maghrebi: Supervision. Montasser Jameleddine Kacem: Supervision, Validation.The authors have no conflicts of interest to declare.


Fishhook injuries commonly occur and may present as ophthalmic surgical emergencies. Choosing the appropriate removal technique is critical and depends on the involved extra- and intra-ocular structures and hook characteristics. We describe the case of a challenging fishhook removal where a novel surgical technique was developed. An eight-year-old boy presented with a full-thickness fishhook injury to the eyelid. During removal surgery, the thickness and density of the fishhook prevented surgical tools from transecting the shank. A novel approach was deemed necessary for safe removal, termed the clamp and retract technique. To our knowledge, this is its first documented use in the literature. Angling has been practiced for hundreds of years and continues to be a popular tradition in sports, the commercial industry, and cultural practices around the globe. Modern-day lures commonly consist of one to three branching shanks with either a barbed or barbless hook. Fishhook injuries commonly occur and, in some cases, may present as ophthalmologic emergencies. Thus, prompt evaluation of extra- and intra-ocular structures and identification of hook characteristics are critical for determining the appropriate removal technique.Penetrating globe injuries and removal techniques have been well documented in the literature -3. HowevThe patient was an 8-year-old boy who presented with a single-barbed fishhook embedded in his left lower eyelid Figure . InitialThe patient was brought into the procedure room, where general anesthesia was introduced uneventfully. The patient’s left eye was prepped with ophthalmic betadine and draped in the usual sterile ophthalmic fashion. The left lower lid was noted to have a large, single-barbed fishhook passing full thickness, sparing the globe. With corneal protection, an attempt was made to cut the fishhook barb with wire cutters following the advance, and the cut removal technique, however, was unsuccessful. Due to the degree of force required to attempt this cut, it was deemed unsafe to continue. Instead, Kelly forceps were used to clamp and flatten the barb against the tip of the fishhook, creating a smooth surface against the fishhook. The fishhook was then retracted through the entry wound without resistance Figure .The wound and eye were again thoroughly flushed with sterile irrigating and povidone-iodine solutions. After surgery, the fishhook was sent for culture Figure . A dilatNo complications resulted from the surgery. On follow-up examination of both eyes, the patient’s vision returned to baseline at 20/20 in each eye and was only significant for a 1.5mm well-approximated wound at the left external lower lid, connecting full thickness to a 1mm wound just internal to the lid margin. The left lower palpebral conjunctiva had 1+ injection, and the bulbar conjunctiva had 1+ injection inferiorly but was otherwise white, quiet, intact, and Seidel negative. The cornea had no evidence of abrasion or laceration, and the anterior chamber was deep and quiet. The iris was grossly normal, and the lenses and vitreous were clear. Dilated fundus with macula and periphery were noted to be normal.Several other techniques with good surgical outcomes have been documented in the literature, but they require extra incisions, instruments, and operating time ,2. The vThe retrograde technique best suits barbless or small and superficially placed barbed hooks . The shaThe needle cover technique has been demonstrated most helpful in removing fishhooks of the posterior segment of the eye . For extThe advance and cut technique is widely used for extra-ocular fishhook injuries . The shaWhen determining the appropriate removal technique, it is essential to consider extra- and intraocular structures involved and the type of fishhook in question. It is critical to rule out the possibility of a global injury, as this would be the most severe of cases and require immediate surgical attention by an ophthalmologist . In deteDetermining whether the hook has shanks and, if so, how many is essential. In cases where the involved hook point is not visible but has exposed shanks, the non-involved shanks may be used as a reference to help in identification. This is possible because fishhook shanks are commonly uniform on individual lures. The uninvolved shanks should then be covered with tape to prevent further injury during retraction . If the This is the first case reported using Kelly forceps to clamp and flatten the fishhook barb to allow retrograde removal through the eyelid wound entrance. No suture was needed for this removal, and our patient regained baseline vision without ocular complications. This case may contribute to the literature on an additional successful way of a common injury seen in ophthalmology.


Cellular angiofibromas (CAFs) are infrequent and benign soft-tissue tumors that primarily affect the genitourinary region in both genders. The authors report the case of a 71-year-old male patient who exhibited progressively increasing swelling in both testicles, with greater prominence noted on the left side. Initial findings from physical examination and scrotal ultrasound indicated the possibility of bilateral hydrocele, so the patient was recommended surgical intervention of the left more prominent side. Intraoperatively, a left paratesticular mass was identified and subsequently excised. Histopathological analysis confirmed the diagnosis of cellular angiofibroma. Surgeons should be cognizant of this tumor type to optimize treatment strategies, as local excision demonstrates a potential to preserve the testicle and yield favorable outcomes. Although occurrences of local recurrence are extremely rare, long-term follow-up is imperative. Cellular angiofibromas (CAFs) are uncommon benign soft-tissue tumors that predominantly manifest in the genitourinary region. These tumors affect both genders, typically appearing during the fifth decade of life . In womeHistopathologically, CAFs are primarily characterized by bland spindle cells containing short bundles of wispy collagen. Additionally, small- to medium-sized vessels with mural hyalinization are commonly observed. Neoplastic cells in CAFs demonstrate positive expression of CD34 and epithelial membrane antigen (EMA). Chromosomal analysis has indicated the potential presence of RB1 deletion on chromosome 13q14 -8.Clinically, CAFs can be challenging to suspect due to their association with conditions such as hydrocele testis and/or inguinal hernias. The definitive diagnosis of cellular angiofibroma is established through histological examination, and the tumor's location serves as an essential clue in the diagnostic process .Complete excision represents the sole curative treatment -9. To daA 71-year-old Caucasian male patient was referred to the surgical department with complaints of swelling in the left testicle that started four months after a left inguinal hernioplasty. The patient had previously undergone hernioplasty as an outpatient, using the plug and mesh technique. Following an ultrasound study, the urology consultation diagnosed bilateral hydrocele, with the left side exhibiting a more pronounced swelling. As the patient had already been operated on by General Surgery, it was agreed with the Urology department that the general surgeons would do the hydrocele corrective surgery.The patient's medical history included a previous diagnosis of colorectal adenocarcinoma (T3N1M0), for which he had undergone rectum anterior resection and adjuvant chemotherapy two years prior and was considered cured. Additionally, he had a medical history of atrial fibrillation, arterial hypertension, hyperuricemia, dyslipidemia, and class I obesity (BMI 31 kg/m2), medicated with Rivaroxaban, Ramipril, Allopurinol, and Simvastatin. There were no relevant family history details pertaining to this case.InvestigationsPhysical examination revealed asymmetrical enlargement of both testicles, with the left scrotum demonstrating a more significant increase in volume. Transillumination and fluctuation tests were positive bilaterally, while impulse on coughing was negative. Palpation of the testicles did not elicit any pain. No other findings were reported on urogenital and rectal examination. Ultrasound examination confirmed the presence of simple fluid collection on both sides. No masses or alterations were detected. Doppler sonography was not performed.TreatmentThe patient provided consent for drainage of the left hydrocele and eversion of the tunica vaginalis. During the procedure, an oval-shaped soft paratesticular mass measuring approximately 10 cm × 10 cm × 4 cm with rich vasculature was found. The mass appeared to be attached to, but not invading, the scrotal part of the spermatic cord. The tumor was completely resected Figures , and hydOutcome and follow-upHistopathology reports described a nodular fragment measuring 300 g and 11 cm × 12 cm × 4 cm. The outer surface was partially covered with a fibrous membrane, while the remaining surface had a fleshy, grayish-brown appearance. Upon sectioning, the surface displayed a vaguely fatty appearance with slightly hemorrhagic areas and regions of increased consistency.Microscopically, the lesion exhibited expansive growth without an obvious peripheral capsule. It consisted of numerous small to intermediate-sized vascular structures within a typically lax stroma. The cellular component demonstrated oval nucleus elements without significant atypia, with discrete mitotic activity (Ki67 less than 5%). The vascular structures often displayed hyalinized walls and occasional intravascular thrombosis. In other sections, the neoplasm resembled granulation tissue with marked interstitial edema surrounding the vascular structures. Proliferating cells showed immunoreactivity for Bcl2 and EMA.There were no postoperative complications, and the patient was discharged on the first postoperative day. Regular follow-up examinations were conducted, and there were no reports of recurrence during the two-year period. However, after the two-year follow-up, the patient, unfortunately, succumbed to septic shock of respiratory origin.Cellular angiofibroma is a rare mesenchymal tumor characterized by its generally well-circumscribed shape .Patients with CAF typically present with a slow-growing painless mass, with a median duration of 5 months . HoweverClinically, these tumors can be misdiagnosed as an inguinal hernia, despite not exhibiting pulsation during the Valsalva maneuver. In this specific case, despite not having been operated on for the first time in the authors’ department, it is possible that the patient never had an ipsilateral inguinal hernia, and if so, the testicular mass may have gone unnoticed due to its small dimensions. Another specific aspect of this case was the presence of bilateral hydrocele, which served to camouflage the mass, probably significantly smaller at the time of the scrotal ultrasound. Therefore, it is crucial to conduct a careful and thorough objective examination along with an ultrasound study. In cases of doubt, further investigation should be pursued, even for small masses.Diagnostic imaging modalities for CAFs include ultrasonography with color Doppler, CT scan, and MRI. The appearance of cellular angiofibroma on imaging studies can vary, with some tumors demonstrating hyperintense signals on T2-weighted MRI images or density changes on CT scans due to their vascularity -14. HoweHistologically, CAFs exhibit distinctive features. These tumors are typically well-circumscribed, cellular, and composed of spindle-shaped cells with short bundles of collagen, fusiform nuclei, and pale eosinophilic cytoplasm. Notably, numerous thick-walled and hyalinized vascular structures are observed. Cellular atypia or necrosis is not commonly detected .Immunohistochemically, CAFs typically show positive staining for vimentin, CD34, and estrogen receptor (ER), while they are negative for desmin, smooth muscle actin (SMA), S100 protein, and epithelial markers. The presence of CD34 and ER immunopositivity further supports the vascular and hormonal characteristics of CAFs. These distinctive histological and immunohistochemical features aid in the accurate diagnosis and differentiation of CAFs from other spindle cell tumors and help guide appropriate clinical management [The diagnosis of CAF is typically based on several key factors, including its specific anatomical location in the vulva-vaginal and inguinal-scrotal regions, the histopathology of spindle-shaped cells, the expression of specific marker proteins by tumor cells, and the absence of one of the two RP1 genes. Distinguishing CAF from two other spindle-shaped cell tumors, namely myofibroblastoma and spindle cell lipoma, can be challenging, as these tumors also commonly exhibit tumor cells with deletions in one of their two RP1 genes. However, certain distinguishing features such as the presence of hyalinized blood vessels and the expression of CD34 and desmin proteins in cellular angiofibroma can be useful in setting it apart from myofibroblastoma .Once the diagnosis of CAF is established, the treatment of choice is surgical excision with tumor-free margins. In this case, at the time of surgery, a definitive diagnosis was not available. However, since the mass was easily isolated from the testicular and peri-testicular structures, a decision was made to spare these organs. Two urologists were consulted during the procedure, and they agreed with the surgical approach .In conclusion, this case report presented a rare occurrence of CAF. The diagnosis of this type of tumor is challenging due to its nonspecific clinical and radiological features, often leading to misdiagnosis or unnecessary invasive procedures. The case highlights the importance of accurate histopathological evaluation and immunohistochemical analysis to confirm the diagnosis. While surgical excision remains the mainstay of treatment for CAFs, long-term follow-up is necessary to monitor for any recurrence or associated complications. Future research and case studies are needed to further explore cellular angiofibroma's pathogenesis, molecular characteristics, and potential therapeutic targets.


Catamenial pneumothorax (CP) is reported to be caused by the endometriosis of diaphragm, lung and parietal pleura. Therefore, the resection of endometriotic lesion in these organs is reported as effective surgical treatment. Overlooking of endometrial tissues during the operation is believed to be the cause of recurrence after surgical treatment. To address this problem, we underwent total diaphragm covering (TDC) and total pleural covering with sheets of oxidized regenerated cellulose mesh. This report described two CP cases that underwent total diaphragm covering (TDC) and total pleural covering. Both patients were followed up for 1 year without recurrence. To prevent its recurrence, surgical resection of the endometrial tissues of these organs is performed as effective treatment . Howeveret al.  reportedA 42-year-old woman with a history of endometriosis who was treated with hormonal therapy visited our hospital because of recurring pneumothorax of the right lung. The last pneumothorax was 1 year ago. The pneumothorax persisted for 20 days with chest tube insertion, and video-assisted thoracoscopic surgery (VATS) was scheduled. During the surgery, endometrial lesions of the diaphragm and parietal pleura were observed . No lungCase 2 was a 40-year-old woman with a history of endometriosis treated with hormonal therapy who came to our hospital because of recurring pneumothorax. The last pneumothorax was 3 months ago. The pneumothorax persisted for 7 days with chest tube insertion, and VATS was scheduled. During the surgery, many endometrial lesions of the diaphragm and lung were observed . We reseThe recurrence rate after surgery of CP was relatively high 30–32%) , 2 compa% , 2 comet al for the treatment of LAM. After TPC, the visceral pleura is approximately five times thicker than the untreated portions, whereas extensive pleural symphysis accompanying fibroblast proliferation and collagen deposition [TPC is a surgical technique, which the surgeons cover the entire visceral pleura with ORC mesh for reinforcement, reported by Kurihara position . We hypoIn this report, both patients who were treated with TDC and TPC were followed up for 1 year without evidence of recurrence. This suggests that the effectiveness of the treatments. In Case 2, there were more endometrial lesions than we could resect, and the residual lesions were covered with ORC mesh. The positive outcome of Case 2 suggests that TDC and TPC method may also be effective for cases that endometrial lesions could not be completely resected.In conclusion, TDC and TPC methods may be effective in reducing CP recurrence. Further treatment using this strategy may be performed and reported.None declared.None.The data underlying this article cannot be shared publicly or protecting privacy of individuals that participate in this study. The data may be shared on reasonable request to the corresponding author after additional approval by the Institutional Review Board of Japanese Red Cross Society Nagano Hospital.


Developmental midline nasal masses including nasal dermoids (NDs), encephaloceles (EPHCs), and nasal glial heterotopias (NGHs) are a consequence of disrupted embryonal developmental processes in the frontonasal region. Surgery is the only method of treatment in order to prevent local and intracranial inflammatory complications as well as distant deformities of the facial skeleton. Due to their rarity, similar location, and clinical and radiological symptoms, meticulous preoperative differential diagnostics is mandatory. The aim of this thorough literature review was to present and discuss all clinical, histopathological, and radiological aspects of NDs, NGHs, and EPHCs that are crucial for their differential diagnosis. A disruption of embryonal developmental processes in the frontonasal region may result in the formation of a group of rare midface malformations described as developmental midline nasal masses. These lesions include nasal dermoids (NDs), encephaloceles (EPHCs), and nasal glial heterotopias (NGHs). Although related to identical locations and considered for many years as disorders of similar embryological origin, many aspects of these disorders are the subject of ongoing debate.NDs constitute the majority of congenital midline nasal masses, accounting for at least 60% of these abnormalities ,2. The tEPHCs are described as a herniation of intracranial components through the developmental defect of the skull base. They are defined depending on their content. Meningoceles are the protrusion of meninges, whereas meningoencephaloceles are masses containing meninges, cerebrospinal fluid (CSF), and brain tissue ,5,6. DepNGHs are similar to EPHCs to some degree, but the main difference is that NGHs represent an absence of communication with the CNS or subarachnoid space ,16. A maThe majority of these developmental masses are located in the nasal region, extranasally or intranasally, or in its immediate proximity. Surgery is the only method of treatment in order to prevent local and intracranial inflammatory complications, as well as distant craniofacial deformities . Due to The aim of this literature review was to present and discuss in detail the clinical, histopathological, and radiological aspects of NDs, NGHs, and EPHCs that are crucial for differential diagnostics.NDs may present as a cyst, sinus, or fistula located anywhere from the philtrum of the upper lip to the glabellar region . A hair An ND is a non-expansile and non-pulsatile mass that is not compressible and does not transilluminate ,35. The EPHCs may manifest as a nasal mass, a widened nasal bridge, hypertelorism, telecanthus, epiphoria, a nasal obstruction, or feeding difficulties depending on the location ,20,37,38Approximately 15% of all EPHCs are located anteriorly and called sincipial or frontoethmoidal EPHCs. Among them, nasoethmoidal, nasofrontal, and nasoorbital EPHCs can be distinguished. A nasoethmoidal EPHC is diagnosed when the herniation protrudes through the osseous defect between the ethmoid and nasal bone (through the foramen caecum). In these cases, a pathological, bluish mass is located on the nasal root or in the nasal cavity . The medTo avoid further facial deformities during growth and potential CNS infectious consequences, all sincipial encephaloceles should be surgically treated at an early age .Basal EPHCs are intranasal, smooth “polypoid”, pink or bluish, and covered with mucous membrane masses ,5,39; a In contrast to NDs, the Furstenberg sign is positive as EPHCs enlarge  with jugular vein compression, the Valsalva maneuver, or spontaneously during crying ,5,36.EPHCs may be accompanied by other craniofacial abnormalities, such as malformations of cortical development, median cleft face syndrome, and hydrocephalus ,41. The Due to the similarities in clinical manifestation, EPHCs have to be taken into consideration in the differential diagnostics of EPHCs, NDs, and NGHs.An NGH is regarded as an EPHC that has lost the intracranial connection . NGHs arExtranasal glial heterotopias are usually seen at the glabella or along the nasal dorsum . They maIntranasal glial heterotopias are attached to the middle turbinate or lateral nasal wall . These lThe term dermoid cyst customarily covers a few histopatologically different entities. It has been used to describe epidermoid cysts, true dermoid cysts, and teratoid cysts . TeratoiNot only are there some clinical similarities between NGHs and EPHCs, but the histopathological differences have also not been clearly determined. Both lesions are composed of varying proportions of neurons and glia .The dysplastic neuroglial components mainly include astrocytes, but occasionally also gemistocytic astrocytes, neurons, or ependymal cells. Although Penner et al. reported ependymal components and neurons in 20% of their samples, usually no significant leptomeningeal, ependymal, or choroid plexus structures are identified . The mulPenner at al. revealed that lymphocytes and macrophages or other chronic inflammatory cells were present in all cases of NGH . MoreoveThe variety of histological pictures requires more than routine hematoxylin-eosin staining. Thus, some additional special staining and immunohistochemistry (IHC) processes have to be implemented ,53,54,55It should be highlighted that no significant histopathological differences exist in particular NGHs, regardless of the presence of a central nervous system connection.Penner et al. identified factors influencing difficulties in the identification of glial components . IntenseEPHCs are histologically similar to NGHs. The surface of these pathological masses is covered with a columnar or cuboidal epithelium and dense fibrous dura-like bands . In someMahapatra et al. revealed that none of the frontoethmoidal EPHCs among their group of 92 pediatric cases contained any significant brain elements . The casStandard hematoxylin-eosin staining is supported by immunohistochemistry . Additionally, brain glial tissue is positive for neuron-specific nuclear protein (NeuN) . NeuN isA comparison indicates that NGHs and EPHCs are histologically similar. Some authors claim that cystic structures with ependymal cells are features that distinguish EPHCs from NGHs ,61. But The diagnostic protocol is similar for NDs, NGHs, and EPHCs. Computed tomography (CT) or magnetic resonance imaging (MRI) remain the standards for presurgical management in all midface nasal masses. Regarding NDs, MRI presents slightly higher values of sensitivity, specificity, predictive positive value, and predictive negative value towards intracranial extension in NDs compared to CT . TherefoAs children below the age of 5 are more predisposed to false-positive and false-negative results on imaging regarding intracranial involvement, the combination of CT and MRI should become a gold standard in the diagnosis of nasal dermoids in that age group . TherefoCT enables the most effective assessment of crucial bony elements . Some chMRI, with its higher resolution regarding soft tissues, reveals direct and indirect signs of intracranial penetration ,65,66. NThe diffusion-weighted imaging technique in MRI (DWI) plays an important role in differential diagnosis. NDs are typically represented by high-signal-intensity lesions with a corresponding low signal intensity on apparent diffusion coefficient maps (ADC) ,68. AdilThe differentiation between dermoid and epidermoid cysts may be supported by the diffusion-weighted imaging (DWI) technique. This may reveal diffusion restriction, which is considered to be characteristic of epidermoid cysts but may also be observed in dermoid cysts ,70. RodrAs dermoid and epidermoid lesions are hardly distinguishable on imaging , some auAn accurate preoperative diagnosis is of utmost importance in these lesions, as it allows one to prevent catastrophic sequlae ,9. The mSome authors have highlighted the supportive role of digital angiography or angioresonance in evaluation for the presence of possible vascular structures in EPHCs . CerebraAdil et al. highlighted that severe difficulties in proper diagnosis using MRI may appear in the case of a superimposed infection in an older child with a congenital EPHC. It can be hardly distinguishable from sinusitis with a bony defect and secondary EPHC .Differential diagnosis focuses on the confirmation of discontinuity with the brain parenchyma ,13. The Dysplastic tissue usually corresponds to no enhancement ,74; howeThe most important clinical, histopathological, and radiological features of NDs, NGHs, and EPHCs are summarized in The similarity between hemangioma and NGHs in clinical manifestation and, to some degree, in MRI increases the risk of a potential pitfall in diagnosis ,74. SomeNone of the proposed theories concerning the embryopathological processes underlying the formation of the discussed nasal masses are convincing and unambiguous alone. The recent research has focused on the subject of the molecular and genetic background of these congenital abnormalities. Because of the complexity of the processes involved in the abnormal development of the facial region, many factors are still unknown . The fur


Vein of Galen aneurysmal malformation (VGAM) is a rare, congenital, intracerebral arteriovenous malformation with a poor prognosis. This disorder commonly presents during the neonatal period and rarely in infancy and childhood. Reported here is a case of VGAM in a three-month-old female baby who presented with proptosis and intracranial calcifications, which are rare presentations of this rare entity. The diagnosis was confirmed by magnetic resonance imaging (MRI). Vein of Galen aneurysmal malformation (VGAM) is a rare congenital arteriovenous malformation caused by fistulous connections between cerebral arteries and cerebral veins leading to an abnormally persistent and dilated median prosencephalic vein of Markowski, which serves as an embryologic precursor to the vein of Galen. This occurs between the sixth and eleventh week of gestation and has a male predominance . SymptomAn 86-day-old female baby presented to the ophthalmology department with a two-week history of swelling and redness of the left eye and two episodes of generalized tonic-clonic seizures. There was no history of trauma or eye discharge. She was born at 39 weeks of gestational age to a 27-year-old G1P1 via spontaneous vaginal delivery and weighed 2.7 kg at birth. Her antenatal, family, and medical history were unremarkable.General physical examination revealed a temperature of 98.6⁰F, heart rate of 130 beats per minute, blood pressure of 78/41 mmHg, respiratory rate of 32 per minute, and oxygen saturation of 100% on room air. The baby had pallor, a capillary refill time of less than 3 seconds, and weighed 4.1 kg. The shape of the head was normal. Left eye proptosis and dilated episcleral vessels were noted. A neurological examination revealed a drowsy child. Power, tone, bulk, and reflexes were within normal limits. There were no signs of meningeal irritation. Respiratory, cardiovascular, and gastrointestinal system examinations were unremarkable.Cerebral computed tomography (CT) and MRI scans were requested for further characterization. Noncontrast CT of the brain showed intracranial calcifications in the subcortical white matter of the parietal lobes and periventricular regions of the frontal lobes bilaterally. Ventricles appeared mildly dilated. Increased subarachnoid space was noted in bilateral frontoparietal regions suggestive of benign enlargement of subarachnoid space in infancy Figure .A TORCH  panel was sent because of intracranial calcifications, which turned out to be negative.MR images showed a characteristic appearance of VGAM with a large flow void in the midline, posterior to third ventricle extending to the straight, left transverse, left sigmoid, left superior petrosal sinuses, and left cavernous sinuses and the left superior ophthalmic vein. Numerous arterial feeders were seen along the anterior wall of the VGAM Figures -4.This patient subsequently underwent endovascular embolization.VGAM is a rare form of embryonic arteriovenous shunt, which consists of multiple feeding arteries draining into the median vein of the prosencephalon, which fails to regress between 6 and 11 weeks of gestation . It accoVGAMs are sometimes detected in late antenatal and neonatal transfontanellar ultrasound scans. The dilated median prosencephalic vein (MPV) appears as an anechoic structure in the midline posteriorly and demonstrates prominent flow on Doppler examination. However, diagnosis on an antenatal scan is not a common occurrence due to the low pressures in the venous system before birth . Plain rContrast-enhanced CT shows a well-defined, midline, intensely enhancing lesion with the cistern of velum interpositum. This is often associated with dilatation of ventricles, periventricular white matter hypodensities and calcifications, and diffuse cerebral atrophy. The parenchymal calcifications can be attributed to chronic venous hypertension and ischemia leading to the secondary development of dystrophic subcortical white matter calcifications . MRI augDigital subtraction angiography is diagnostic and therapeutic and remains the gold standard for the evaluation of VGAMs. It allows us to precisely demonstrate the angioarchitecture of the malformation and catheterize feeders supplying the fistula. Endovascular embolization has now become the optimal approach for VGAM with a good clinical outcome and acceptable mortality. The prognosis depends on the size of the shunt and the presence of cardiac failure in utero ,9.VGAMs commonly present with high-output cardiac failure in the neonatal period. However, they should be considered as a differential diagnosis in children presenting to the ophthalmology department with proptosis. Although rare, radiologists should include VGAM in the differential diagnosis of intracranial calcifications in children. Untreated VGAMs are almost always fatal. Hence, it is of utmost importance to diagnose this challenging condition as early as possible to initiate proper management.


Peritoneal inclusion cyst is a rare benign condition with low potential for malignant transformation but high recurrence rates. Debulking surgery is the recommended first line management for these patients, however, recurrence rates are up to 50 % .A 26-year-old male being worked up for non-specific abdominal pain with cross-sectional imaging showing multiple multicystic lesions in the abdomen and pelvis. There was a pre-operative suspicion of Pseudomyxoma Peritonei and decision was made for diagnostic laparoscopy and biopsy. Mucin and an abnormal small bowel mesentery was found intraoperatively and sampled leading to the diagnosis of peritoneal inclusion cyst.Treatment of peritoneal inclusion cyst range from surveillance to aggressive treatment with complete cytoreductive surgery with involved field peritonectomy and hyperthermic intra-peritoneal chemotherapy.First line management of peritoneal inclusion cysts is for debulking surgery. Arguments for less invasive and more aggressive management has been proposed, however, further data needs to be collected to determine gold standard of treatment. •Peritoneal inclusion cysts previously known as multicystic peritoneal mesothelioma•Benign pathology but has a high risk of recurrence•Most commonly affects women over men•Current mainstay treatment is debulking surgery. He reported no history of weight loss, night sweats or changes to appetite. His past medical, drug and social history was unremarkable. He had a benign abdominal examination with no masses palpable. Bloods and tumour markers, colonoscopy, and upper endoscopy revealed no abnormalities. Computerized tomography (CT) of the abdomen and pelvis revealed multiple loculated cystic masses throughout the abdomen and pelvis with a dominant lesion in the pelvis . ProvisiIn October 2022, the patient underwent a diagnostic laparoscopy. Free mucin was found along the right side of the abdomen and pelvis, at the tip of the appendix and the small bowel appeared nodular. Pelvic fluid, visible mucin and peritoneal biopsies were taken. Pathological examination of the mucin showed multiloculated cystic spaces lined by flattened to columnar epithelial cells with features favouring mesothelial cells. Immunostaining confirmed the lining cells to be mesothelial with calretinin and WT1 . No sign3Peritoneal inclusion cysts are extremely rare. They account for 3–5 % of peritoneal mesothelial lesions, however, are benign with a low rate of transformation into malignancy Treatment options for confirmed or suspected peritoneal inclusion cysts are surveillance, aspiration, primary surgical resection, repeat surgical resection in event of recurrence, or CRS and HIPEC 4Peritoneal inclusion cysts are a rare variant of peritoneal mesothelioma. There is a high risk of recurrence and low risk of malignant transformation. Currently first-line therapy is for surgical debulking, however, further research needs to be dedicated to this topic.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethical approval not applicable.N/A.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Dr Callie Killoran accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publishDr Callie Killoran – study design, writing the paperDr Danniel Badri – Study Design, editing the paperDr Alexandra Walton – data analysis/interpretationDr Joanna Perry-Keene– data analysis/interpretationDr Nicolas Copertino – study concept/design, editing the paper.N/A.


A 55-year-old female presented with elastofibroma of the thigh. On presentation, she complained of a palpable, painful mass on the anterolateral right thigh that had been present for one year. She had a history of surgery for a right femur fracture. On MRI, a soft-tissue mass was seen in the vastus intermedius muscle, as a heterogeneous lesion with streaky fatty and fibrous components. The fibrous component was isointense to the muscle, and the fatty component had a high signal on both T1- and T2-weighted images. Histopathological analysis after biopsy established the diagnosis of elastofibroma. Elastofibroma is a benign soft tissue tumor, and it is histopathologically characterized by a mixture of collagen, elastic fibers, and adipose tissue. It is more commonly known as elastofibroma dorsi since it often occurs in the subscapular region. Although previously reported as a rare tumor, an autopsy study has shown a prevalence of one in four people in the elderly population . There aA 55-year-old female patient presented with the complaint of a palpable, painful mass on the anterolateral right thigh for one year. The patient's history was remarkable for the open reduction and internal fixation with a plate and screws for a mid-1/3 diaphyseal fracture of the femur following a car accident in 1984. The implant had been removed one year after the surgery. Physical examination revealed scar tissue approximately 20 cm in length on the lateral thigh and a mass that was painful on palpation on the middle third right anterolateral thigh.The radiographs showed cortical irregularities and thickening of the femur correlating with the history of fracture surgery. MRI showed an unencapsulated mass adjacent to the middle third of the femur with relatively well-defined margins. On T1 and T2 images, the tissue was seen to have fatty and fibrous components like tiger stripes. On gadolinium contrast T1 images, there was a heterogeneous low level of enhancement  Figure .A diagnosis of elastofibroma was made based on the clinical, radiological, and histopathological findings. The diagnosis was discussed with the patient. Based on the literature search, an MRI of the contralateral thigh and subscapular regions was performed, and no lesions were observed; hence, it was decided to implement a conservative follow-up.Elastofibroma is a benign soft-tissue tumor characterized by fibroblastic/myofibroblastic differentiation as per the World Health Organization soft-tissue tumor classification . AlthougElastofibroma is frequently seen in the subscapular area and is uncommon in other regions -4. AccorRadiological examination is an important step in the diagnostic process. On ultrasonography, elastofibroma appears as a lesion containing fatty tissue, and streaky collagen or elastic fibers with a relatively well-defined margin . RadiogrFor lesions that do not have typical imaging features, a definitive diagnosis can be reached with histopathological examination. The diagnosis of elastofibroma is significant because malignant tumors are included in the differential diagnosis ,14. AlonWe described a common case of elastofibroma with an atypical location. Despite the fact that imaging studies can establish the diagnosis of elastofibroma with high accuracy, a histopathological examination may still be required for a definitive diagnosis, especially for tumors with an atypical location.


Hemangiomas are the most common benign liver tumour. These tumours arise from the proliferation of vascular endothelial cells and increase in size owing to dilation. If their diameter exceeds 5 cm, they are classified as giant hemangiomas, while those surpassing 15 cm are considered enormous hemangiomas.A 38-year-old female patient presented with complaints of abdominal fullness for 18 months. Contrast-enhanced computed tomography was performed and two hemangiomas were diagnosed; the , larger one was an enormous hemangioma of size 20 × 16 cm. Non-anatomical hepatic resection was performed to remove the hemangiomas. The patient recovered well, without any complications.Hepatic hemangiomas are common, but hemangiomas greater than 15 cm in size are rare. They usually require no treatment unless the patient is symptomatic. Hepatectomy and enucleation of hemangioma are the most common surgical procedure for such hemangioma.Rarely, large hepatic hemangioma can be the cause of abdominal fullness lasting for months. Often, surgical intervention is required. HighlightsHemangiomas are the most common benign tumour of liver.Hemangiomas exceeding 15 cm in greatest diameter are considered enormous hemangioma.Rarely, large hepatic hemangioma can be the cause of abdominal fullness lasting for months.Hepatectomy and enucleation of hemangioma are the most common surgical procedure for such hemangioma.1. However, only a small number of them grow to a size exceeding 5 cm, and only those larger ones may cause vague abdominal symptoms2. These neoplasms consist of groups of blood-filled cavities lined by endothelial cells, and they are thought to be vascular malformations that enlarge through dilation instead of hypertrophy or hyperplasia3. Haemangiomas are frequently discovered incidentally during imaging tests for other unrelated pathologies, and they are part of the “Incidentaloma” tumour group1. The cause of these tumours is not fully understood, but hormonal factors, such as exposure to oestrogen and progesterone during pregnancy or hormone replacement therapy, may play a role in their enlargement4. However, not all haemangiomas have oestrogen receptors, and some have been known to grow without hormonal replacement, even in post-menopausal women4. Due to the unpredictable growth pattern and ambiguous symptoms of liver haemangiomas, there is significant interest in their epidemiology and diagnosis, despite being a commonly found benign tumour. This case report has been reported in line with the SCARE  criteria5.Hemangiomas are the most prevalent liver tumours, accounting for ~20% of casesA 38-year-old woman presented to our institution Out-Patient Department with complain of abdominal mass for last one and half year. She also reported experiencing abdominal fullness, shortness of breath, and loss of appetite in the past one to two months but denied experiencing any abdominal pain, jaundice, or irregular menstrual flow, had no family history of liver diseases, and was not taking any medications. Upon physical examination, a large, non-tender, firm mass measuring around 20 ×15 cm was detected in the right hypochondriac region extending towards the umbilical region.Ultrasonography of abdomen was done which revealed an ill-defined, heterogeneous isoechoic lesion measuring ~13 ×12 cm with a central hypoechoic area and internal vascularity. Suspecting hepatic hemangioma, contrast -enhanced computed tomography was done which showed two well-defined hypodense lesions in the liver, one measuring 19 ×18 × 12 cm and exophytic in nature, arising from segments V, VI, and IVb and medium (3–10 cm) hemangiomas are well defined and do not require treatment apart from regular follow-up. However, giant liver hemangiomas, reaching upto 10 cm or even exceeding 15 cm, termed as enormous hemangioma, often develop symptoms and complications1.Hepatic hemangiomas are the most common benign tumours of the liver8.Di Carlo and colleagues’ 2016 study defined four size categories of hepatic hemangioma. They reviewed reports from 1970 to 2014 and found 154 patients with haemangiomas smaller than 5 cm , 182 between 5 and 9.9 cm (large), 75 between 10 and 14.9 cm (giant), and 102 exceeding 15 cm (enormous). They concluded that the term ‘giant’ should be used for tumours larger than 10 cm, and surgery should only be considered if the patient experiences symptoms like abdominal discomfort or haematological alterations9. For centrally located giant hemangiomas, resection is preferred over enucleation to minimize the risk of significant bleeding. Percutaneous ablation is an option only for lesions smaller than 5 cm, and in such cases, observation is favored over intervention, resulting in the infrequent use of this approach1. In our case, we opted for a non-anatomical resection of the liver using the Kelly and clamp method and harmonic scalpel after angioembolization. This approach has been shown to be safe and effective for treating large hemangiomas and minimizing blood loss during surgery10.In this case report, we presented the case of a 38-year-old woman who had an enormous hepatic hemangioma measuring 20×16 cm . Ribeiro and colleagues’ literature review suggests that in healthy patients without comorbidities, surgical resection is universally recommended for true giant liver hemangiomas larger than 10 cm. This is due to the risk of catastrophic rupture, especially when they are situated in areas prone to abdominal rupture. Surgery is absolutely necessary in cases of spontaneous or traumatic rupture with hemoperitoneum, intratumoral bleeding, and the extremely rare Kasabach–Merrit syndromeWe presented a rare case of an enormous hepatic hemangioma in 38-year-old lady with symptom of abdominal fullness. Sometimes, it may exceeds 15 cm in size requiring surgical treatment. The successful management of this lesion using a non-anatomical resection after embolisation of feeding vessel highlights the importance of careful planning and coordination between interventional radiology and surgery teams.Not required for a case report in our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on requestThe authors received no financial support for the research, authorship, and/or publication of this article.P.B.: wrote the original manuscript, reviewed, and edited the original manuscript. P.M., D.R. and K.K.: reviewed the original manuscript. S.P. and N.M.: reviewed and edited the original manuscript. R.S.B.: senior author and manuscript reviewer.Authors have no conflict of interest to declare.Name of registry : None.Unique Identifying number or registration ID : None.Hyperlink to your specific registration (must be publicly accessible and will be checked): None.Pratik Baral Is guarantor for this manuscript.All available data are within the manuscript itself.Not commissioned, externally peer- reviewed.The authors express their gratitude to the patient for granting consent for the publication of this case report. Additionally, the authors extend their thanks to the Department of Gastrointestinal and Hepatobiliary Surgery of their institution, as well as to all the healthcare professionals, including doctors and nurses, who were involved in the patient’s care. Without their support and dedication, this report would not have been possible.


Colonic extranodal mucosa-associated lymphoid tissue lymphoma as a cause of hematochezia is rare. Here, we report a case of colonic extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALToma) with presentation of freshy bloody stool and successfully treated by endoscopic mucosal resection.This case was a 69-year-old woman with history of hypertension, reflux esophagitis, and peptic ulcer. She had several episodes of hematochezia and thus sought medical attention at the outpatient clinic.Colonoscopy revealed a 12-mm semipedunculated lesion in the ascending colon. Histopathological examination and immunochemistry were compatible with colonic extranodal mucosa-associated lymphoid tissue lymphoma.Endoscopic mucosal resection was done for tumor removal and hemoclipping was done to achieve hemostasis.The patient remained well without recurrence during 3 years of outpatient follow-up.En bloc endoscopic resection could achieve long-term remission. The prognosis of colonic MALToma is excellent with its indolent characteristics.Colonic MALToma is a rare disease, and could present as hematochezia.  The most common primary site is the stomach, followed by the eye/adnexa, skin, lung, and salivary glands.,3 Colonic MALToma is rarely seen. In recent years, new case studies regarding clinical features, treatment modalities and clinical outcome of colonic MALToma have been proposed. Here, we present a case with presentation of hematochezia and successfully treated with a good outcome. We also conducted a literature view of previous case reports published in PubMed database between 2018 to 2023.Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALToma), first described in 1983 by Isaacson and Wright,This 69-year-old woman presented at the outpatient clinic with several episodes of fresh bloody stool. She had a diagnosis of hypertension, reflux esophagitis, and peptic ulcer. However, she had not received follow-up care for 2 years. She reported no use of cigarettes or alcohol. There was no family history of colorectal cancer or familial adenomatous polyposis.Helicobacter pylori was seen in the superficial gastric pits by hematoxylin and eosin staining. Computed tomography of the chest, abdomen, and pelvis revealed no involvement by lymphoma. A whole-body positron emission tomography was also arranged for tumor screening, revealing negative results. Her hematochezia resolved and repeat colonoscopy confirmed no recurrence of tumor. She remained well during 3 years of outpatient follow-up.The physical examination was unremarkable. She received a colonoscopic examination performed up to the cecum, which revealed a 12-mm semipedunculated lesion with nodular surface and a type I pit pattern in the ascending colon , followed by the right colon (13.6%), and sigmoid colon (8.2%), reported in a review of 50 case reports of colorectal MALToma from 1993 to 2017. The 5-year survival rate is 92.5% in the United States (US) statistics. The tumor recurrence rate is also low (6.8%). The pathogenesis is not well-illustrated, contrary to gastric MALToma in that H pylori infection results in chronic inflammation environment, recruitment of B-cells, and H pylori-specific tumor-infiltrating T-cells, contributing to proliferation of MALToma. Only 19.2% of colonic MALToma was reported to be H pylori positive.Colonic MALToma is a subtype, accounting for 4.8% of all MALToma.,5 as the presentation of our case. The endoscopic findings are variable. Solitary polypoid lesions were more frequently reported. Flat, elevated, semipedunculated, and ulcerated lesions were also demonstrated.,5 A review of case reports showed a median size of 20 mm of tumors, which is appropriate for EMR. Histologically, MALToma comprises of polymorphous lymphoid cells, including monocytoid B-cells, centrocyte-like cells and small lymphocytes. Scattered immunoblasts and centroblast-like cells as well as plasmacytoid differentiation are also seen. Immunohistochemically, MALToma is typically positive for B-cells markers , BCL2, negative for BCL6, CD5, CD10, and CD23, in accordance with our case. The chromosomal translocations include t, t, t, and t, which are involved in the NF-kB pathway.The clinical presentations are usually mild or asymptomatic, ranging from incidental finding at screening colonoscopy, abdominal discomfort, a positive fecal occult blood test, bowel habit change, to melena or hematochezia,Till now, no consensus guidelines have been established for treatment, which is possibly due to the rarity of the disease. To evaluate the treatment modalities and treatment response in recent published cases, we performed a literature view of previous case reports via a PubMed search of “ AND ” between January 1, 2018 to February 28, 2023. Cases with concomitant cancer or previous cancer history, congenital disorder, involvement of gastrointestinal tract other than the colon, non-English publications, or incomplete documentation were excluded. A total of 11 cases were included, presented as Table H pylori eradication, endoscopic resection, surgery, chemotherapy, radiotherapy, and observation. The treatment response was excellent in the reviewed 11 cases, except for one with recurrence, and rescued by endoscopic submucosal dissection (ESD). Among previous case reports and literature view, some studies showed tumor regression by H pylori eradication, even in H pylori-negative cases, the mechanism of which is still not elucidated well.,16 Eradication of unknown bacteria or antibiotic effects inhibiting tumor development had been proposed.,6 The rate of complete remission by H pylori eradication (80%) in one review was not inferior to other treatment modalities significantly. In localized stages, EMR, ESD or surgery with en bloc resection achieve long-term complete remission in most cases, while radiotherapy is usually used as either a first-line or combined treatment.,11 Chemotherapy is more commonly used as a first-line treatment in advanced stages or second-line treatment for recurrence.,8 The regimens are various, including rituximab in combination with other agents or rituximab alone. There were also cases having no progression of disease without disease-specific treatment, indicating that a watch-and-wait strategy is possible in selected cases.–6 Few cases still experienced disease progression or treatment failure, with the need of second-line therapy.,5 Overall, the prognosis of colonic MALToma is excellent with indolent characteristics, usual presentations of localized stages, and good response to treatment modalities.The treatment modalities include There were a few limitations in this study. First, only English-written studies were included in the literature view. Publications written in other languages might also provide important information of the disease. Second, cases with MALToma involving multiple sites of gastrointestinal tracts besides the colon were not evaluated. Third, the majority of cases in this study were in localized stages. Future studies including more cases with advanced stages are warranted to obtain a more comprehensive understanding of this disease.As illustrated in our case, colonic MALToma has clinical presentation of hematochezia and endoscopic resection either with EMR or ESD with complete removal of tumor results in long-term remission in a localized stage. Our case highlights that physicians’ awareness and alertness to freshy bloody stool or any non-negligible symptom leads to prompt diagnosis of colonic MALToma, and in our case it eventually came with a great outcome after a successful treatment.Supervision: Wei-Yu Kao, Chun-Chao Chang.Writing – original draft: Chien-Hung Lu.Writing – review & editing: Yu-An Kan, Wei-Yu Kao, Chun-Chao Chang.


Gallstone ileus is a rare condition characterized by mechanical obstruction of the intestine due to gallstone impaction. Diagnosis is based on clinical history, symptoms, and characteristic Computed Tomography (CT) scan findings. Treatment typically involves surgical extraction of gallstones, with laparoscopy as an effective and potentially safer approach. Here, we describe a case of an 84-year-old woman with gallstone ileus presenting with small bowel obstruction. Gallstone ileus is a rare complication of cholelithiasis, in which a gallstone becomes lodged in the intestines causing an obstruction. It is observed in only 1%-4% of bowel obstruction cases and is common in older females , 3, 4. IAn 84-year-old woman presented to our hospital with a week-long history of abdominal pain, nausea, vomiting, and constipation. She was unable to tolerate oral intake due to worsening symptoms. She had no prior history of biliary colic or cholecystectomy but had a hiatal hernia noted on esophagogastroduodenoscopy (EGD) six months ago for gastroesophageal reflux disease (GERD). Her medical history included coronary artery disease, hypothyroidism, and an abdominal aortic aneurysm status post-endovascular repair. On admission, vital signs were within a normal range, but the physical examination was remarkable for epigastric tenderness and decreased bowel sounds. There was no rebound tenderness or guarding. Laboratory workup was unremarkable except for an elevated creatinine to 1.80 mg/dL, higher than her usual baseline of 0.80 mg/dL, consistent with acute kidney injury (AKI).A computed tomography (CT) abdominal and pelvis without contrast demonstrated intraluminal cholelithiasis and gas suggestive of pneumobilia with extrahepatic duct pneumobilia Figure . The surMagnetic resonance imaging (MRI) of the abdomen without contrast demonstrated a cholecystoduodenal fistula and sub-centimeter calculi within the gallbladder Figure . Small bThe patient subsequently underwent laparoscopic removal of the gallstone in the mid-ileus, cholecystectomy, and surgical repair of the duodenotomy fistula site. The surgery was well-tolerated by the patient. Samples from the cholecystectomy were evaluated for malignancy in the pathology lab. Immunohistochemical stains with Ki-67 and p53 showed no dysplasia, ruling out cholangiocarcinoma entirely.Gallstone ileus, a rare condition complicating 0.3%-0.5% of cases of cholelithiasis with a female-to-male ratio of 3.5 to 1, was first described by Bartholin in 1654 during an autopsy . GallstoGallstone ileus presents with symptoms often consistent with small bowel obstruction, including nausea, vomiting, constipation, dehydration, colicky abdominal pain, and abdominal distension. Symptoms can be intermittent due to the "tumbling phenomenon," where gallstones dislodge and travel distally, causing temporary relief of symptoms. Laboratory investigations may be unremarkable or nonspecific , 7. A hiGallstone ileus requires surgical removal of the gallstone to relieve bowel obstruction. The three common surgical approaches include enterolithotomy alone, enterolithotomy combined with cholecystectomy and fistula closure (one-step surgery), and enterolithotomy followed by delayed cholecystectomy with fistula closure, usually 4-6 weeks later (two-step surgery) , 12. EntUpon admission, our patient exhibited symptoms indicative of small bowel obstruction consistent with Rigler's triad, accompanied by characteristic imaging findings, culminating in a diagnosis of gallstone ileus. The patient underwent laparoscopic surgery that was completed without any issues and was successful in one step. This case highlights the importance of timely diagnosis and the safety and effectiveness of laparoscopic management for gallstone ileus.Gallstone ileus is a rare form of intestinal obstruction that can present with typical or nonspecific symptoms. It is important to maintain a high level of suspicion for prompt diagnosis, which is typically done through abdominal CT. Management involves surgical removal of the gallstone, which can be done through laparotomy or laparoscopy.


A 62-year-old patient, non-smoker, with prior medical history of hypertension was referred to Rheumatology. The patient described pain and right (RT) ankle-joint swelling. He mentioned a gradually progressive pain in his joints, that amplified with exercise. He also denied any recent trauma or overuse. He had no fever, chills, sweats, or other constitutional symptoms.Following a physical examination revealed swelling of ankle-joint, moderate pain on palpation, without redness or warmth difference between his left (LT) ankle-joint. Metatarsal joints were not affected and no other significant signs from musculoskeletal system were observed. X-ray imaging of the RT foot did not reveal any signs of fractures, osteoarthritis or chondrocalcinosis and no joint effusion was presented.The laboratory workup was unremarkable with normal inflammatory markers, normal RF, uric acid, and no autoantibodies. Serological test came back normal.Figure 1A). Further Magnetic Resonance Imaging confirmed the presence of a solid heterogenous mass with dimensions 1.6x2.5x2.8cm .Ultrasound sonography revealed a heterogeneous mass on the outer front portion of the ankle .Over the next weeks, surgical resection of the mass was performed as to undergo further histopathological analysis. The microscopical examination confirmed the diagnosis of a classic benign giant cell tumour of the tendon sheath. The tumour presented a small hyperchromatic fused oval shaped cells with several large osteoclasts such as multinucleated giant cells scattered throughout with few dilated vessels and oedema but no cellular atypia  required further evaluation with imaging tools when osteoarthritis exacerbation, crystal arthropathy, infectious and systemic rheumatic diseases are carefully ruled out.