Primary colorectal leiomyosarcoma is an excessively rare entity. It is associated with an aggressive behavior and typically favor hematogenous spread. The current standard of care is surgical resection. A 49-year-old patient presented with a 2-month history of fever. A PET-scan revealed a hypermetabolic mass in the transverse colon, and colonoscopy confirmed a tumor. A right hemicolectomy was performed. Histopathological diagnosis was of a leiomyosarcoma. Fourteen months after the surgery, a follow-up abdominal scan revealed a 2 cm mesenteric lymph node that was hypermetabolic on PET-scan. The mesenteric lymph node was resected and histopathology confirmed a leiomyosarcoma metastasis. This case opens the controversy on the management of rare lymph node recurrences in colorectal leiomyosarcoma. Primarytochezia . The statochezia , 11. Thetochezia . This arA 49-year-old woman was evaluated for a fever of unknown origin that started 2 months prior to her visit. A wide panel of investigations and imaging testing was performed. An elevated level of C reactive protein (CRP) (160 mg/L) was noted. A positron-emission tomography (PET) scan revealed a hypermetabolic mass adjacent to the wall of the transverse colon . A colonThe patient underwent surgical exploration, and a right hemicolectomy was performed. Histopathological evaluation showed a 5 × 4 cm tumor composed of malignant fusiform cells. Immunohistochemical analysis was positive for vimentin, h-caldesmon, CD10, smooth muscle actin, and keratin AE1/AE3 and negative for desmin, WT1, EMA, PAX8, DOG1, CD117, CD34, keratin 5/6, S100, and p63. Ki-67 was estimated at 5-10%, and mitotic count was 10 per 10 high power fields (HPFs). Resection margins were negative. Fifteen lymph nodes were harvested and were free of metastasis. The patient recovered uneventfully from the surgery.The case was presented at the institutional cancer committee, and the joint decision was to not initiate adjuvant treatment. She had a normal follow-up abdominopelvic scan four months after the surgery. Fourteen months after the surgery, a second follow-up abdominopelvic CT scan showed a suspicious enlarged 2 cm mesenteric lymph node. It was described as necrotic and located under the pancreas. This lymph node showed hypermetabolism on the PET-scan with a maximum standardized FDG-uptake value (SUV) of 7.1 .A laparotomy was performed to allow adequate access to the lymph node. A 3 cm mass was identified between the superior mesenteric artery and the splenic vein and was resected. Histopathology showed a neoplastic proliferation of pleomorphic spindle cells arranged in fascicular and storiform patterns, compatible with a leiomyosarcoma . One lymThis rare case was presented again at the institutional cancer committee, and the decision was to proceed with clinical follow-up without adjuvant chemotherapy. Eight months after the surgery, the patient is disease free.Colorectal leiomyosarcoma is an exceedingly rare entity, accounting for approximately 0.1% of all colorectal cancers –4. OtherThe diagnosis of leiomyosarcoma is more commonly made after the evaluation of the surgical specimen. Leiomyosarcomas are malignant tumors derived from smooth muscle cells of the colonic muscularis propria . Tumor cThe main histological differential diagnosis of a primary colonic leiomyosarcoma is a gastrointestinal stromal tumor (GIST) . GISTs, Complete resection of colonic leiomyosarcomas is rarely described in the literature, with less than 20 cases reported . The immThe most widely accepted and performed treatment with colonic leiomyosarcomas is surgical excision , 10, 11.The role of systemic therapy for colorectal leiomyosarcoma is controversial. Most authors do not recommend initiation of a systemic chemotherapeutic agent, as the majority of leiomyosarcomas are chemoresistant , 21. StuRadiotherapy is not recommended for the treatment of colorectal sarcomas, mainly because these tumors are frequently radioresistant , 13. TheColorectal leiomyosarcomas are associated with limited survival and a poor prognosis. The overall 5-year survival is between 20 and 44% . FactorsWe presented here a rare case of mesenteric lymph node recurrence of primary colorectal leiomyosarcoma. These are rare entities associated with an aggressive behavior and represent a diagnostic challenge. Current standard of care is surgery alone. More studies are required to evaluate the impact on prognosis and subsequent management of nodal involvement in colorectal sarcomas.


Focused abdominal sonography in trauma (FAST) and contrast-enhanced computed tomography (CECT) abdomen are important radiological tests for evaluating the abdomen in polytrauma cases. When vitals are stable, they help to reach a diagnosis in the majority of patients. However, in a small number of cases they fail to explain the clinical scenario. A continued serial clinical assessment may be helpful in these circumstances. A polytrauma patient was found to be FAST positive. The CT scan revealed pulmonary embolism, splenic infarction, perisplenic and perihepatic hematoma. The patient was complaining of pain abdomen and it worsened on day three of the injury. An exploratory laparotomy was performed. A circumferential intestinal wall hematoma with a tear in mesentery was found. This is a rare case of traumatic splenic infarction with evidence of pulmonary embolism. The serial clinical assessment was helpful as it indicated the need for intervention. Polytrauma cases with abdominal symptoms are frequent at emergency. Focused abdominal sonography in trauma (FAST) is usually the first investigation in such cases. If FAST is positive and the vitals are stable, then contrast computed tomography scan of the abdomen is performed. But even with this in some cases the diagnosis remains elusive. In presence of persisting symptoms, a serial clinical examination should be performed. Worsening of abdominal symptoms or appearance of abdominal signs should prompt for emergency exploratory laparotomy. In trauma cases with blunt injury to the abdomen, serial clinical examination is very useful especially if there is a suspicion of bowel or mesenteric injury.A 42-year-old female presented to the casualty with road traffic injuries. She was crossing the road when a tractor hit her. She arrived six hours after the injury in a hemodynamically stable condition with Glasgow Coma Score (GCS) of 15. She was complaining of lower abdominal pain and there were multiple bruises and abrasions on her torso and thighs. The lower abdomen was tender on palpation. Bedside focused assessment with sonography in trauma (FAST) was performed and free fluid was noted in the perisplenic and perihepatic windows. A computed tomography (CT) scan of chest, abdomen, and pelvis was performed. There was evidence of pulmonary embolism in the right pulmonary artery Figure . Pelvic A provisional diagnosis of pelvic fracture with pulmonary embolism and splenic infarction was made. Departments of pulmonary medicine, cardiology, and orthopedics were consulted. Electrocardiogram (ECG), troponin-T, 2-dimensional echocardiogram (2D ECHO), retinal examination, and D-dimer assays were performed. In ECG, the ST segment was elevated and the test for troponin-T was positive. Other tests were normal. Conservative treatment with injection enoxaparin, injection ceftriaxone, and pain killers was started. Vitals and oxygen saturation were monitored continuously and we examined the abdomen every eight hourly during the first 24 hours. We enquired about the symptoms and performed palpation, auscultation, and abdominal girth measurement at these times. The frequency of examination was reduced to twice daily after the first day as the vitals and the hematocrit were stable. During the first two days, there was mild to moderate continuous lower abdominal pain but it was soft on palpation.On day three, the pain became colicky and was spread all over the abdomen. She was not passing flatus or motion since one and a half days. The pulse rate was 112/min and the blood pressure 98/68 mmHg. The abdomen was distended and was tender on deep palpation. The bowel sounds were exaggerated. On digital rectal examination, the rectum was empty. In view of deteriorating symptoms and possibility of intestinal obstruction, an exploratory laparotomy was performed. There was a small contusion a small mesenteric tear in the ileum around 100 cm proximal to the ileocecal junction Figure . The splThe post-operative period was uneventful and the patient was shifted to orthopedics department for further management.The splenic artery is an end artery and its occlusion results in splenic infarction. The infarct usually resolves spontaneously without any complication. Miller et al. studied 13 patients with traumatic splenic Infarction. They followed 11 of them with computed tomography scans. They found that in the majority the spleen recovered to normal within a few days [Pulmonary embolism is a known complication of major trauma. O'Malley et al. studied 1316 patients of trauma who survived for more than one day and found evidence of pulmonary embolism in 30 of them. Pelvic fracture, age above 55 years, and severe trauma were major factors responsible . HypotheThe risk of early death in pulmonary embolism is categorized into high-risk and non-high-risk. This is based on three markers - clinical markers, right ventricular dysfunction markers, and myocardial injury markers. The non-high-risk cases can be managed with anticoagulants only . The troEvaluation of the abdomen in trauma is complex. Serial clinical examination and computed tomography scan of the abdomen are useful in hemodynamically stable patients. Serial clinical examination includes physical examination of the abdomen and recording of vitals and hematocrit every eight hourly during the first 24 hours. This is usually not continued after 24 hours in penetrating trauma. However, in blunt trauma the duration of observation is not well defined ,6. CT scIn our case CT scan revealed multiple emboli, hemoperitoneum, and bony injuries. There was evidence of pulmonary embolism, splenic infarction, and embolus in intrahepatic IVC. We started injection enoxaparin and observed the abdomen. We performed exploratory laparotomy because the abdominal pain was not subsiding and CT scan was not able to explain this. An unsuspected intestinal injury was detected. Prolonged serial clinical assessment helped in managing this case. Splenic infarction with pulmonary embolism is a rare and serious complication following trauma.Splenic infarction with pulmonary embolism is a rare and serious complication following trauma. Computed tomography scan and serial clinical assessment was helpful in managing this case. We identified most of the injuries with CT scan and a missed intestinal injury was detected on prolonged clinical assessment. Splenic infarct resolved spontaneously and the pulmonary embolism was managed conservatively.


Due to the risk of malignancy, the established management of choledochal cysts mandates bile duct excision and biliary reconstruction. While the reconstructive procedure of choice for most surgeons has traditionally been hepatico-jejunostomy, this may not be feasible in selected cases due to immobility or inadequacy of the jejunum. The following case will outline the management of a 32-year-old woman with short bowel syndrome, who was diagnosed with choledocholithiasis and a type 1 choledochal cyst.As a child, our patient suffered midgut volvulus secondary to malrotation which resulted in extensive bowel resection and developed short bowel syndrome. She presented with recurrent bouts of cholangitis. Imaging of her biliary tree confirmed common duct stones extending into the branched hepatic ducts, as well as a fusiform dilatation of the common bile duct, that appeared consistent with a type 1 choledochal cyst. Laparoscopic excision of the cyst with reconstruction using a hepatico-duodenostomy was planned.The patient underwent successful laparoscopic cholecystectomy, CBD clearance with excision of the bile duct and reconstruction with hepatico-duodenostomy. Recovery was uneventful and she is asymptomatic on subsequent follow-up. Histology is consistent with a markedly dilated bile duct rather than a choledochal cyst.This case illustrates the dilemma of diagnosis and treatment of a dilated bile duct mimicking a choledochal cyst in the setting of short bowel syndrome and the feasibility of a laparoscopic approach in such cases. Also, it demonstrates that hepatico-duodenostomy may be a safe alternative in cases with limited material for conduit. Among tA variety of surgical reconstructive procedures have been described. The two most commonly used are Roux-en-Y hepatico-jejunostomy and hepatico-duodenostomy . Althoug2A 32-year-old woman presented to the hospital with a history of right upper quadrant pain and jaundice. She was diagnosed with gallstones a couple years before this presentation and was counselled on having cholecystectomy prior to pregnancy for which she was desirious. Interestingly, she had undergone extensive resection of gangrenous bowel as a child, secondary to intestinal malrotation and midgut volvulus. She remained with 100 cm of small intestine that was anastomosed to the transverse colon, and subsequently developed short bowel syndrome. Despite compensating well, she eventually developed cholelithiasis and extensive choledocholithiasis, resulting in recurrent bouts of acute cholangitis. On this admission, an ultrasound of the abdomen showed multiple stones in the gallbladder, as well as a dilated common bile duct measuring 1.8 cm in diameter. Imaging of her biliary tree identified common duct stones extending into the branched hepatic ducts, as well as a fusiform dilatation of the common bile duct, that appeared consistent with a type 1 choledochal cyst .Fig. 1MRGiven these findings, a surgical approach was determined to be the best option to allow for excision of the cyst and biliary reconstruction. Although the preferred method of reconstruction was a Roux-en Y hepatico-jejunostomy, this was precluded by this patient's limited intestinal length. Therefore, laparoscopic cholecystectomy with clearance of the biliary tree, choledochal cyst excision and hepatico-doudenostomy was planned.This was done with the patient in Lloyd-Davies position and the use of visual port entry at Palmer’s point. As expected, on achieving peritoneal access, significant adhesions were encountered and divided before identifying the gallbladder and proceeding with laparoscopic cholecystectomy. The critical view of safety (Strasberg) was attained, and the gallbladder dissected off the liver with the cystic structures intact. Cephalad retraction of the gallbladder faciliatated exposure of the hilar structures proximally and an extensive Kocher's manoeuvre was performed to mobilise the duodenum . The mobThis dissection was extended to the intrapancreatic segment distally, at which point a transverse choledochotomy was done to extract the common bile duct stones. Clearance of the proximal and distal ducts was achieved by repeated flushing with saline and multiple passages of a fogarty catheter until clear. The proximal duct was divided at the hilar region, just below the confluence of the right and left hepatic ducts. The distal duct was transected with a linear stapler device. A tension-free hepaticoduodenostomy was performed using intra-corporeal suturing technique using interupted 3/0 absorbable Vicryl suture .Fig. 4Inhttps://1drv.ms/v/s!AkSawWgNOFMogb8d0YCJqqF2jeHXUQ.A short video outlining the key aspects of the procedure can be accessed using the following link: The procedure lasted just under four hours, and the patient was discharged on day 3. She had an uneventful recovery and remains asymptomatic on subsequent follow-up. Despite the preoperative radiological findings, histological examination was consistent with a markedly dilated bile duct rather than a choledochal cyst. Written consent was obtained from the patient allowing for publication of this case and use of operative footage. IRB approval was not required in this case.3The earliest attempt of biliary construction using laparoscopic techniques was a laparoscopic cholecysto-jejunostomy in 1992, although since then more advanced procedures have been attempted ,8. LaparThe most common methods of reconstruction for these cases are the Roux-en-Y hepatico-jejunostomy and the hepatico-duodenostomy. Although most surgeons favour the former due to a perceived lower complication rate, it may not always be possible as illustrated in our case. Furthermore, a review of the literature reveals that there is significant debate as to whether the concerns related to hepatico-duodenostomy are in fact warranted, with some authors suggesting that this should be the preferred method of reconstruction .A report by Todani et al. found no significant difference in early complications between the two procedures, although hilar cholangiocarcinoma was observed 19 years after hepatico-duodenostomy in one case ,16. AnotA large single centre study published in the Indian Journal of Surgery in 2012 reviewed the use of hepatico-duodenostomy for biliary reconstruction following choledochal cyst excision in 54 patients over a 25-year period. Most patients had an uneventful postoperative recovery, however, three episodes of biliary leak were noted which settled with conservative management. An anastomotic stricture was observed in one patient 18 years after the initial procedure. In this series, hepatico-duodenostomy was appraised as a relatively safe procedure with low complication rates . A meta-Our case posed several unique challenges and presented both diagnostic and therapeutic dilemmas. In a patient who has presented with complicated gallstones disease and recurrent episodes of cholangitis, the ideal management would usually comprise endoscopic clearance of the bile duct followed by laparoscopic cholecystectomy. The presence of multiple stones extending proximally into the hepatic ducts of this patient precluded endoscopic clearance in favour of a surgical drainage procedure such as a choledocho-duodenostomy. The fusiform dilatation of the common bile duct, however, further complicated matters, mandating excision of the apparent choledochal cyst and biliary-enteric reconstruction. Although hepatico-duodenostomy was successfully used in this case, some may argue that its possible long-term consequences make it a less attractive option for younger patients with longer life expectancy.However, in such cases where limited intestinal length may prevent other methods of reconstruction, hepatico-duodenostomy is a viable option. When compared to hepatico-jejunostomy, it requires a single anastomosis and is easier to perform. In addition to providing a better physiological result, it also preserves endoscopic access to the biliary tree which we feel is a great advantage not only if a leak or stricture occurs but also for surveillance and biopsy. A literature search for similar cases was performed, and 1 case was discovered, performed by Tan et al. using similar techniques, at the University Kebangsaan Malaysia Medical Centre, which was published in 2011 .4This case illustrates the dilemma of diagnosis and treatment of choledochal cysts  in patients with short bowel syndrome. Similar to other studies, laparoscopic bile duct excision and reconstruction was found to be feasible, and no complications were observed in the early postoperative period. Despite the theoretical long-term risk of anastomotic stricture, the preserved access afforded by hepatico-duodenostomy facilitates endoscopic intervention. Therefore, hepatico-duodenostomy should be considered a safe alternative in selected cases with limited material for conduit.This submission is a case report and therefore no funding was required.Exemption of ethical approval was provided by the institution.Written consent from the patient was obtained for publication of this case report.Dr. Ammiel Arra – Primary author and editor of video.Dr. Dilip Dan/Dr. Nigel Bascombe/Dr. Barrie Landreth-Smith – Surgeons involved in patient’s management. Provided review of article prior to submission.Dr. Maria Bartholomew – Gastroenterologist involved in patient’s care. Provided review of article prior to submission.Article submitted was a case report and therefore not applicable.All authors were involved in the preparation of this case report.Primary Surgeon – Prof. Dilip Dan.Not commissioned, externally peer-reviewed.None of the authors have any conflicts of interest to declare.


Syphilis is an infectious disease that has afflicted mankind for centuries, but a recent increase in worldwide incidence has been evidenced. The authors describe a patient with typical lesions of secondary syphilis and moth-eaten alopecia, whose dermoscopic examination demonstrated empty hair follicles, vellus hair, follicular hyperkeratosis, peripheral black dots, dilated and tortuous vessels, reddish brown background, and hypopigmentation of the hair shafts. Furthermore, this case presented an erythematous background more evident than previously described cases. Syphilis is an infectious disease that has afflicted mankind for centuries. Epidemiological data show that the incidence has increased over the last years throughout the world.A 29-year-old man, infected by HIV five years ago, had been using antiretroviral therapy with a history of poor adherence. His last CD4 demonstrated 674 cells and a viral load of 417 copies. He presented erythematous-brown, infiltrated plaques on the face, trunk, and arms, as well as areas of multiple non-healing alopecia, with poorly defined borders, present in the occipital region of the scalp . A biopsSA is an uncommon manifestation of syphilis infection. In 1940, McCarthy described two clinical types of SA, symptomatic and essential, the latter being divided into three patterns: moth-eaten or patchy alopecia, diffuse alopecia, and mixed-pattern alopecia. This classification continues to be used, practically unchanged. Although the clinical aspects of SA are well described, the trichoscopic findings have been demonstrated in scant publications in recent years, detailed in 7Symptomatic SA is the most rare manifestation, in which there is an association of skin and scalp lesions, simultaneously. The essential SA is characterized by capillary loss, with no other visible syphilitic lesions. Moth-eaten alopecia is the most common, presented by multiple plaques of non-cicatricial alopecia, in the absence of local inflammation or scaling. They occur mainly in the parieto-occipital region, but may also arise in other areas such as beard, eyelashes, armpits, pubis, trunk, and legs. The diffuse SA is caused by capillary loss, like telogen effluvium. The mixed form is characterized by small irregular plaques that develop along with diffuse alopecia.9SA has several differential diagnoses, such as alopecia areata , lupus, trichotillomania, tinea capitis, lichen planus pilaris, and telogen effluvium.Treponema pallidum in the affected follicles, supporting the theory of a specific immune reaction to treponemal antigens. Immunohistochemistry can show the presence of spirochetes, generally in the peribulbar and perifollicular regions, indicating that this microorganism has a direct pathogenic role in alopecia.Recent molecular studies have identified The patient in the reported case has presented the rarest form of alopecia, called symptomatic, due to the presence of skin and scalp lesions simultaneously. At dermoscopy, the typical signs described in the literature, such as vellus hairs, empty hair follicles, follicular hyperkeratosis, peripheral black spots, hypopigmented hairs, and dilated and tortuous vessels were visualized on an erythematous-brown background. However, the most striking feature was erythema more intense than the others reported, which may correspond to a symptomatic lesion of secondary syphilis. Trichoscopy can facilitate the diagnosis of SA in a patient with capillary loss of unknown origin.None declared.Izabella Cristina Cardozo Bomfim: Approval of the final version of the manuscript; conception and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of the data; critical review of the literature; critical review of the manuscript.Mayra Ianhez: Approval of the final version of the manuscript; conception and planning of the study; participation in the propaedeutic and/or therapeutic conduct of the cases studied; critical review of the manuscript.Hélio Amante Miot: Approval of the final version of the manuscript; conception and planning of the study; critical review of the manuscript.None declared.


Congenital high airway obstruction syndrome (CHAOS) is complete or partial obstruction of the fetal upper airway. CHAOS is a rare and fatal condition if no perinatal intervention is done. Antenatal sonographic imaging has typical findings that can help in an early diagnosis, which is important in deciding elective termination of the pregnancy or successful planning of appropriate perinatal management. Congenital high airway obstruction syndrome (CHAOS) is a rare life-threatening disorder caused by complete or near-complete obstruction of the fetal upper airway –7. It waHere, we report a case of congenital high airway obstruction syndrome due to laryngeal atresia diagnosed on routine antenatal ultrasound examination at 18 weeks of gestation. We also review the relevant literature in brief.30 years old gravida 2, para 1) with a history of 18 weeks of pregnancy came to our department for a routine second-trimester antenatal ultrasound examination. In the family history, except for first-cousin marriage, there was no significant history predisposing to genetic/familial disorders. Ultrasound examination was performed, and it showed a single viable intrauterine fetus with bilateral enlarged echogenic lungs and dilated fluid-filled trachea. Small centrally displaced heart, flattened diaphragm, cleft lip, and cleft palate were also noted  , 8.Normally, the fluid secreted by fetal lung is absorbed through the tracheobronchial tree , 4. HoweThe main pathology is an intrinsic obstruction of the upper airway. Laryngeal atresia is the commonest cause. However, tracheal atresia/stenosis, laryngeal/subglottic stenosis, laryngeal webs, and laryngeal cysts are other possible causes of CHAOS , 12, 14.Though the majority of the cases of CHAOS are sporadic, approximately half of the cases of CHAOS are associated with congenital anomalies, especially of the skeletal system , 7, 8. TIn our case, parents refused autopsy; however, they agreed for genetic/chromosomal analysis which, unfortunately, could not be performed due to technical reasons.Imaging is used to document the typical radiological features of CHAOS and to investigate the cause and level of the airway obstruction; intrinsic causes  versus extrinsic causes  , 12, 15.CHAOS can be diagnosed on routine antenatal ultrasound examination as early as 16 weeks 13. Ultrasound is the first-line imaging modality of choice in antenatal diagnosis of CHAOS due to its widespread and easy availability as well as its low cost . UltrasoAmniotic fluid volume is variable and depends on the gestational age of the fetus and other associated congenital anomalies/syndromes; for example, oligohydramnios is seen in early pregnancy and cases associated with Fraser's syndrome. Polyhydramnios (caused by compression of the esophagus by enlarged lungs and dilated airways) is seen in late pregnancy , 2, 4, 7Classical sonographic features of CHAOS are bilateral boggy hyperechoic lungs, fluid-filled dilated airways, small compressed and centrally displaced heart, flattened/inverted diaphragm, and ascites. All these sonographic features can also be demonstrated on MRI , 10, 16.Sometimes pulmonary enlargement may resolve spontaneously which may be secondary to spontaneous perforation of dilated airways or trachea-esophageal fistula , 6, 14. Our case was diagnosed at 18 weeks of gestation and had characteristic sonographic features. Amniotic fluid amount was normal on initial scan; however, follow-up scan at 30 weeks of gestation showed interval development of polyhydramnios. Fetal ascites and generalized subcutaneous edema were also noted on follow-up scan. Depending on the degree of dilatation of the trachea, we assumed that the level of airway obstruction was in the upper airway, likely at the level of larynx, which was confirmed by laryngoscopy after delivery. Our patient also had cleft lip and cleft palate which were noted on both ultrasound examinations. We could not find any association of this anomaly with CHAOS in literature and failure of genetic analysis also did not help us in establishing/excluding such association. We presumed it was likely an incidental finding.The differential diagnosis of CHAOS includes other common fetal hyperechogenic lung lesions like congenital cystic adenomatoid malformation (CCAM) and pulmonary sequestration. CCAM is usually unilateral  and can show spontaneous resolution during pregnancy. It can also be differentiated from CHAOS by tracheal enlargement which is specific for CHAOS. Pulmonary sequestration is differentiated from CHAOS based on systemic arterial supply , 6, 14.Previously, CHAOS was considered a lethal disease with a grave prognosis , 4. HoweAlthough, the commonest cause of airway obstruction in CHAOS is laryngeal atresia; rarely isolated stenosis or web, which are usually associated with normal laryngeal anatomy, may be the cause of airway obstruction and release of such obstruction can ultimately restore normal lung development . FetoscoFetal MRI may help in patient's selection that can benefit from fetoscopic tracheoplasty by determining the level and approximate length of the obstruction . Fetal lIn conclusion, congenital high airway obstruction syndrome is an uncommon cause of proximal airway obstruction which is not compatible with life if no perinatal intervention is done. Antenatal sonographic imaging has typical findings that can help in establishing an early and accurate diagnosis. MRI is used as an adjunct diagnostic tool, particularly in determining the level of airway obstruction and in excluding extrinsic causes of airway obstruction. MRI is also especially important if any perinatal fetal intervention is planned.


Cholesterol polyps are the most common benign gallbladder polyps and are usually seen in a background of cholesterolosis. Rarely, they can harbor foci of osseous metaplasia, which is an event of uncertain clinical significance that might be confused with cholelithiasis clinically or radiologically. Herein we report the case of a 78-year-old female with a 1.8-cm pedunculated polyp arising in the gallbladder body. Histologic examination showed microscopic foci of osseous metaplasia, characterized by heterotropic bone trabeculae rimmed by osteoblasts and surrounded by osteoclast giant cells. To the best of our knowledge, this case is the third case report of a cholesterol polyp with osseous metaplasia in the English literature. We also review the relative pathogenesis, clinical and pathologic findings, and previous reports. Cholesterolosis is the accumulation of neutral lipid within subepithelial macrophages of lamina propria of gallbladder. Cholesterolosis is a common finding seen in 16% of cholecystectomies, frequently with cholesterol gallstones . The patA 78-year-old female presented to our institution for the evaluation of a gallbladder polyp and pancreatic intraductal papillary mucosal neoplasm (IPMN), which were radiologically identified during a workup for bilateral ovarian masses. She underwent cholecystectomy and bilateral oophorectomy that revealed bilateral serous cystadenofibromata. Gallbladder examination revealed a non-thickened wall with yellow-orange mucosa and a 1.8-cm pedunculated polyp arising in the gallbladder body. The lumen contained viscous, dark green bile with numerous black pigment stones. Histologic examination Figures  showed aGallbladder polyps have an estimated prevalence of 5% in the global population . Of thesGrossly, cholesterolosis appear as yellow streaks on the gallbladder mucosa, the color of lipid droplets within lamina propria, reminiscent of the surface of a strawberry, and called “strawberry gallbladder” . When poHistologically, cholesterolosis refers to accumulation of foamy macrophages that fill the lamina propria. The lesional macrophages have small, dark nuclei with foamy (lipid-filled) cytoplasm. These changes are restricted to the gallbladder, without an extension to extrahepatic bile ducts. Cholesterol polyps have a lobulated architecture with a variable number of branching villous projections. These lobules are filled with foamy macrophages identical to the ones seen in diffuse cholesterolosis. The lining biliary epithelium is histologically unremarkable, and if pedunculated, the stalk is composed of a vascular connective tissue. The presence of lipofuscin pigment within histiocytes or the adjacent gallbladder epithelium is not uncommon. The gall bladder wall shows minimal inflammation unless associated with cholelithiasis. Osseous metaplasia (heterotropic bone formation) within cholesterol polyps has rarely been reported in the English literature Table  14-16].-16.14-16In the gallbladder, osseous metaplasia has been first described to occur with adenocarcinoma . It has The differential diagnosis of cholesterol polyps includes hyperplastic or inflammatory polyps. However, these two don’t have the lipid-filled macrophages and can have inflammation instead. Most gallbladder polyps are benign and require no surgical excision ,13. CholCholesterol polyps are the most common benign gallbladder polyps. Usually they are clinically asymptomatic and found incidentally on imaging or cholecystectomy specimens in a background of cholesterolosis. Rarely, they can harbor foci of osseous metaplasia, which is a rare event of unknown clinical significance, though it might affect treatment options if confused with cholelithiasis clinically or radiologically. We reported a case of a large pedunculated cholesterol polyp with microscopic foci of osseous metaplasia, characterized by heterotropic bone trabeculae rimmed by osteoblasts and surrounded by osteoclast giant cells. Herein, we also reviewed the pathogenesis, clinical and pathologic findings, and previous reports.


Giant true aneurysms of the hepatic arteries are rare. Pseudoaneurysms of the hepatic arteries are more common and are mostly caused by intra-abdominal infection, iatrogenic injury, or trauma. Hepatic or cystic pseudoaneurysms are often successfully treated by embolization owing to their saccular nature as opposed to true aneurysms. We present a case of a patient with a giant true aneurysm of the proper hepatic artery, mimicking Mirizzi syndrome. Open reconstruction was successfully preformed, and the patient made a full recovery. It usually concerns pseudoaneurysms after trauma, intra-abdominal infection, or invasive diagnostic and therapeutic treatment.A 72-year-old Caucasian man was referred for evaluation of jaundice. He had been experiencing postural abdominal pain for more than 1 year. In the past month, the pain was getting worse and he experienced heartburn. He noticed loss of appetite in the past 2 months and lost 8 pounds of bodyweight. During the last weeks, jaundice developed, his urine became dark, and he began having gray-colored stool in the absence of fever, chills, or vomiting. There was no history of hepatitis, nor recent travel outside of the Netherlands. Previous medical history included a transient ischemic attack in 2010. He stopped smoking 15 years ago. Up to 2 months ago he drank 3 glasses of wine a day. Medication included a statin and dual antiplatelet therapy, none of which is known to cause jaundice as a possible side effect.9/L).An outpatient ultrasound examination showed a large aneurysm of 10 cm central in the liver hilum; there were no gallstones. On admission, his vital signs were normal. Physical examination revealed an abdominal mass with an audible murmur in the epigastric region. There were no signs of hepatomegaly. Laboratory findings showed elevated levels of total bilirubin (114 μmol/L), aspartate aminotransferase , alanine aminotransferase , AF (1508 U/L), gamma-glutamyl transferase (1742 U/L), C-reactive protein (33.9 mg/L), and normal white blood count (8.5 10A and B). Also, a small subthreshold infrarenal aortic aneurysm of 5.1 cm was seen. No other intra-abdominal abnormalities were found. Semiacute reconstruction of the hepatic artery was performed. A bypass was created from the common hepatic artery to the bifurcation of the proper hepatic artery, using a reversed autologous saphenous vein graft. Clamping time to the liver was approximately 45 minutes. Arterial flow in the right and left hepatic arteries was preserved, but the gastroduodenal artery had to be sacrificed owing to dissection and subsequent thrombosis.A triple-phased contrast-enhanced computed tomography (CTa) scan revealed a true aneurysm starting in the distal common hepatic artery, reaching up to the bifurcation of the proper hepatic artery of almost 13 cm, causing compression of the common bile duct with intrahepatic bile duct dilatation , A and BC).The total blood loss was 1.5 L; there were no perioperative complications. One day after surgery the total bilirubin level decreased to 50 U/L and the jaundice resolved. AST and ALT levels improved direct after the surgery , suggesting no significant ischemia of the liver had occurred. He was discharged on postoperative day 5 and further recovery was uneventful. Duplex ultrasound examination 1 week after discharge and a CTa scan 4 weeks after discharge showed a patent reconstruction without complications , C.,,,We performed a systematic literature search for visceral aneurysms causing Mirizzi syndrome . Forty aOur patient had no known risk factors for developing a false hepatic artery aneurysm. Although signs of atherosclerosis were present on the abdominal CTa, it seems to be mild and compatible with age. There was no evidence of connective tissue disorders or vasculitis-related disease. As in abdominal aortic aneurysms, the condition is rarely associated with symptoms. Only in the case of rupture or, as in our case, when compression of the common bile duct occurs, do symptoms develop. Our literature search revealed that hepatic or cystic pseudoaneurysms are often successfully treated by embolization. This finding can be explained by the fact that pseudoaneurysms are usually saccular in shape. Because the hepatobiliary vascular tree readily branches into important tributaries, endovascular treatment would impose a risk of occluding a right or left hepatic artery in true hepatic aneurysms, which are usually fusiform in shape. Open reconstruction is therefore the treatment of choice and seems to be feasible and safe. Although very rare, in jaundice a Mirizzi-like mechanism caused by a visceral aneurysm should be considered. If so, open vascular reconstruction seems the treatment of choice, because although embolization might prevent rupture, it would not relieve bile duct compression.Although very rare, in jaundice a Mirizzi-like mechanism caused by a visceral aneurysm should be considered. Open vascular reconstruction seems the treatment of choice.


Congenital perineal lesions are rare and can occur along with other birth defects such as anorectal malformations (ARMs) and urogenital anomalies. A colorectal hamartoma associated with a urogenital anomaly without ARM is extremely rare. We recently treated a newborn with posterior hypospadias and a solid perineal mass diagnosed as a colorectal hamartoma. Congenital perineal lesions are rare and can occur along with other birth defects such as anorectal malformations (ARMs).A neonate born premature at 32 weeks with a birth weight 1,740 g was evaluated for a soft dark pink perineal tumor arising 5 mm from a normal anus with associated normal passage of stools. He had a proximal hypospadias with a bifid scrotum and bilateral testes . AlthouIn the first 6 months the perineal lesion gradually became larger, but part from occasional slight bleeding he remained asymptomatic. At the age of 11 months he underwent a diagnostic examination under anesthesia with biopsy of the lesion. The narrow urethral meatus was found immediately adjacent to the perineal lesion . CystogSurgical excision was scheduled at the age of 18 months. The patient had a bowel wash-out preoperatively. Cystoscopy was performed after meatotomy of the narrow hypospadiac urethral opening and showed a normal bladder, bladder neck, and posterior urethra without evidence of an enlarged utricle, corresponding to the findings of the cystography. The tubular structure entered the bulbar urethra just below the urethral sphincter and it was blind ending. A transurethral catheter was introduced over a guidewire and a suprapubic catheter was inserted. Complete surgical excision of the perineal lesion was achieved with a dorsal approach and the patient in prone position. During the procedure, a small lesion in the perineal urethra occurred and was closed. The sphincter complex was dissected anteriorly, but the rectal mucosa remained intact. After excision of the lesion the sphincter complex was re-approximated.The postoperative course was uneventful. Oral intake was resumed after 5 days of parenteral nutrition and the patient was discharged 6 days after surgery. Pathological examination showed a solid structure consisting of smooth muscle, partly lined with squamous epithelium and partly with colorectal mucosa and with a central cavity of 3 mm lined with cylindrical epithelium with focal goblet cells .Examination under anesthesia 2 weeks postoperatively showed slightly delayed wound healing. The suprapubic tube was removed after micturition without residue. Wound healing was completed 6 weeks after surgery. After extensive consultation with the parents and the multidisciplinary team it has been decided to postpone further surgery for hypospadias correction until the patient is older.Perineal lesions are uncommon and mainly occur in patients with ARM. In a series of more than 2,000 patients with ARM, the incidence of perineal lesions was 1.5%, mainly lipomas, hamartomas, and hemangiomas.The pathogenesis of congenital colorectal hamartomas of the perineum is unknown. Liu et al mentioned that the perineum originates from the tip of the urorectal septum which separates the urogenital sinus from the anorectal tract. The close relation of these structures during embryologic development may explain the association of perineal colorectal hamartomas with developmental anomalies of the anorectal and urogenital tracts.Diagnosis of a protruding perineal lesion must include radiologic examination using ultrasonography and MRI to delineate the extent of the lesion in relation to the surrounding structures  and to detect associated malformations within these structures. Contrast studies can be helpful to exclude a fistula to urogenital or colorectal structures. Biopsy to determine histology may be of additional value if diagnosis after imaging and endoscopic examination is still unclear. Treatment of a perineal lesion after establishing the precise relationship with the surrounding structures is surgical in nature. A careful dissection with special attention to nearby structures like urethra and rectum and use of bipolar coagulation is important for a successful treatment.Congenital perineal masses are mainly reported in association with ARM. Reports of perineal colorectal hamartomas without ARM are exceptional. We describe the third case in a male infant, of a perineal colorectal hamartoma associated with posterior hypospadias. Unlike rectal duplications, no connection to adjacent structures is found in perineal colorectal hamartomas. Given the close relationship of the developing perineum with the urogenital and anorectal tracts, an accurate radiological evaluation and endoscopy of the pelvic organs prior to surgical excision is recommended.


Administration of hyaluronic acid (HA) filler for aesthetic lip augmentation is a routine and common procedure with a low rate of adverse reactions. This case report documents an extremely rare complication of lip augmentation with HA leading to the development of lymphangiomas.Lymphangiomas are uncommon hamartomas of the lymphatic system. Although usually congenital, they can be acquired due to trauma, inflammation, or lymphatic blockage. They may be in the deep or superficial tissues, with superficial forms being either lymphangioma circumscriptum or acquired lymphangioma, also referred to as lymphangiectasia. Acquired lymphangiomas are typically formed by blockage of lymphatic drainage leading to dilation of the lymphatic channels. The diagnosis in our case report is acquired lymphangioma.A 27-year-old female presented with a two-year history of linear swellings in her upper lip. These lumps followed the line where HA filler had been injected four years earlier. Hyaluronidase had previously been used unsuccessfully to remove these lumps. The patient was treated with surgery to excise the lesions. Five masses were excised, and histopathological analysis displayed the presence of variably ectatic lacunae, lined by cells with CD34 expression, a lymph-vascular-endothelial marker. There were also scattered macrophages with CD68 expression in the interstices. These are typical features of a lymphangioma. The patient was satisfied with the excellent aesthetic and functional outcome.To our knowledge this is the first case of a lymphangioma following HA lip augmentation. Although rare, this complication can have aesthetic implications for the patient which may require further treatment or surgery to correct. Hyaluronic acid (HA) is a naturally occurring mucopolysaccharide with a high affinity for water . In humaA 27-year-old female was referred to the local Oral and Maxillofacial Surgery (OMFS) department with lumps in her upper lip. Her medical and social history were unremarkable, and there was no history of trauma to the facial region. She gave a four-year history of continuous dryness and tingling in her upper lip, starting shortly after undergoing lip augmentation with HA in both her upper and lower lips. Approximately a year after the injection of the filler she noticed a swelling in her upper lip, which she thought had gradually increased in size since administration. It was unclear whether the swelling was becoming more prominent, or just more obvious due to degradation of the surrounding HA. Two years prior to referral to the OMFS, the patient had hyaluronidase injections to the upper lip, with no noted improvement.On examination, she had multiple, bilateral, linear, non-tender, and fluctuant swellings in the upper lip. They resembled mucoceles in appearance, although the location of the swellings on the lip did not support this diagnosis. The position of the swellings coincided with the lines of injection of the HA filler. Clinical photographs were taken Figures , 2, and Excision of the lesions were performed without complication, involving longitudinal incisions on the labial aspect of the upper lip. Five submucosal swellings were identified, dissected, and removed. The deep aspect of the swellings were found to diffusely infiltrate into the underlying orbicularis oris muscle, with no clear plane of excision. The excised tissue was then sent for histopathological analysis. On follow-up at 14 months, the surgical site had healed well with an excellent cosmetic result Figures , 4, and The histopathology report documented five pieces of tissue, the largest measuring 11 mm in diameter. The main pathologic feature was variably ectatic lacunae within the connective tissue and between muscle fascicles Figures , 6. WithAdverse reactions to HA fillers are rare with a variably reported incidence of 0.5-8% . HoweverCongenital lymphangiomas are uncommon benign hamartomatous lesions found in the lymphatic system. They are typically painless and slow growing, and are a developmental anomaly, usually presenting before the age of five. They are usually found in the head and neck . SuperfiLymphangioma after lip filler injection is a diagnosis of exclusion as lumps in the lips are likely to be of other causes and can be self-limiting, so other treatments are usually tried first without success. A typical treatment regime for lumps on the lip after filler injection would be to massage the tissues firmly for several days. If the problem does not resolve, nodules can be pricked with a needle and drained or injected with hyaluronidase if caused by the HA filler injection. Following this, occasionally a trial of intralesional steroids is commenced. In our case, hyaluronidase was attempted before referral. Another peculiarity in this case that led to the consideration of other diagnoses was the considerable length of time that the lesions had remained present without resolution.2 or Nd-YAG laser, and cryotherapy can also be used, but these provide symptomatic relief rather than definitive options [Where possible, the definitive treatment of choice for lymphangiomas is surgical excision. Unfortunately, lymphangiomas can be difficult to treat and recurrence rates can be high, with a lower rate of recurrence for superficial lesions . Alterna options .Although the lymphangiomatous lesions described in the report were harmless, the appearance caused by lumps such as these can cause significant psychological distress, and in this case led to a change in the patient’s behavior and a reduction in social activity. It is reasonable to consider that the aesthetically conscious cohort of patients who seek lip fillers may be particularly distressed by complications such as this. Furthermore, given a common differential diagnosis of labial swellings are minor salivary tumors, excision for histological examination would have been advised to rule out neoplastic disease.In summary, lymphangioma is a very rare but possible complication of HA lip filler injection. To our knowledge, this is the first reported case in the literature. For this patient, surgical intervention was required to resolve the complication and rule out other pathology. Surgery resulted in an excellent aesthetic and functional outcome with full resolution of the swelling, dryness, and tingling she initially complained of. Despite the complication that we have described, lip fillers remain a usually safe treatment with limited adverse reactions.


The tumor measured 12.4 × 8.8 cm and was successfully resected through a suprapubic incision of 13 cm. The patient was free of pain after the second post-operative day. A fluid collection near the resection plate was easily drained without bile leakage. The patient had no surgical complications. Radical resection is inevitable for adequate curative therapy of AE and provides clear margins. Robotic surgery is a relatively new and safe option for curative resection of AE lesions, with remarkable advantages for patients and surgeons.We report a case of successful robot-assisted major liver resection in a patient with liver alveolar echinococcosis (AE). A 62-year-old male patient was incidentally diagnosed with a large infiltrative lesion in the right liver lobe suspicious for AE. A radical surgical resection as a right-sided hemihepatectomy was indicated. The operation was carried out  Echinococcus (E.) multilocularis, is widely distributed in the northern hemisphere. Other species are E. granulosus leading to cystic echinococcosis, and E. vogeli and E. oligarthrus, causing polycystic echinococcosis (Alveolar echinococcosis (AE), caused by coccosis .In Europe, the prevalence of AE is low and is estimated at 0.64/100,000 in Germany. Most infections exclusively affect the liver. In patients with very large liver masses and invasion of major hepatic vessels metastases to the lung and less frequently to the brain may occur. There are two treatment options: (1) parasitostatic treatment with benzimidazoles, which is indicated in cases where curative resection is not possible or suitable, and 2) radical resection with safety margins of 2 cm. However, safety margins of 1 mm have also been tolerated without recurrence of disease  radical . FollowiA 62-year-old male patient, incidentally diagnosed with a large infiltrative lesion in the liver during trauma clarification, presented himself in our hospital. An abdominal CT scan was performed to rule out trauma injuries and showed a poorly defined lesion in the right liver lobe suspicious for cholangiocellular carcinoma or alveolar echinococcosis (AE). The patient denied any abdominal or B symptoms, and there was no family history of malignant disease. He lived in a rural area in Germany.E. species 1.541 optical density with a cut-off value of 0.988 and E. multilocularis 1.666 optical density with a cut-off value of 0.625). Immunoblot revealed 7-, 16-, 18-, and 26–28 kDa proteins in size. Blood tumor markers were in the normal range . MRI imaging showed an enormous manifestation of AE in the right liver with microcystic and necrotic components that contacted the right pedicle . The tumor measured 12.4 × 8.8 cm  and was For successful treatment of AE, an expert consensus recommends a multidisciplinary discussion to plan the therapeutic strategy according to the stage of the disease. Preoperative treatment with parasitocidal agents is not routinely suggested in management of AE. However, it has been suggested to stabilize the progression of the disease with parasitocidal agents, which was administered in our patient . RadicalMinimally invasive surgical procedures can improve post-operative mobilization and reduce wound-healing impairment compared with open surgery . RoboticIn the literature, several cases have been reported to undergo robot-assisted treatment of hepatic echinococcosis. Of these, most reports have focused on the approach to patients with cystic echinococcosis, which its management differs from patients with AE. In these patients, total cystectomy, minor, and major liver resections have been mostly utilized, as reported by Magistri et al.  and FelsRupture is a rare complication in AE and has only been described once in the literature due to trauma . The rupIn conclusion, AE is a rare disease that should be considered a differential diagnosis in patients with benign and malignant liver tumors. For adequate curative therapy, AE requires radical resection with clear margins and post-operative anti-parasitic drug treatment. Robotic surgery is a relatively new but safe option for curative resection of AE lesions with benefits for patients and surgeons.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.MG, VF, AR, and AMa prepared and wrote this article. MG, AR, and AMe were involved in managing the patient besides preparing the intraoperative pictures. MG, YK, MS, and AMa wrote and revised the manuscript as well as acted as the corresponding authors. AMe was the main surgeon and involved directly in managing the patient. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


External jugular vein pseudoaneurysm is a very rare cause of a neck mass due to the low pressure venous system. This case demonstrates a 27-year-old female who presented to the emergency department with a non-tender, compressible, left-sided neck mass that enlarged with valsalva and talking, and intermittent paresthesias. Upon workup, she was diagnosed with an external jugular vein pseudoaneurysm. Complications of this diagnosis are mentioned in the literature; however, most patients with an external jugular vein pseudoaneurysm or aneurysm can be safely discharged with close follow-up with a vascular surgeon. Venous aneurysms are very rare compared to arterial aneurysms.7An aneurysm is defined as a dilation of all three layers of the vein wall. The histology of an aneurysm may show thinning of the elastic fiber wall, decreased smooth muscle in the media, and replacement of smooth muscle by fibrous tissue,An otherwise healthy 27-year-old African-American female presented to the emergency department complaining of a left neck mass with associated paresthesias radiating up her left lateral neck and down the left arm. These paresthesias were intermittent and positional. She noticed the mass present suddenly about two months prior to presentation and endorsed gradual increase in size, in addition to intermittent and positional paresthesias. The mass was painless and enlarged with talking and valsalva maneuvers. She denied any recent interventions including massage, chiropractics, or neck manipulation. She had no known personal or family history of connective tissue disease. The patient also denied social history including smoking, alcohol, or substance use. However, she had been in a motor vehicle accident about four months prior without any significant injuries or immediate complications. This was a low-speed crash and the patient was able to self-extricate and self-ambulate without assistance immediately after the injury. No medical evaluation or imaging was completed at that time.On physical exam, she had a 2-centimeter (cm) soft, compressible, non-pulsatile, nontender mass that enlarged with valsalva and talking along the antero-lateral left neck . The masBasic blood work showed no abnormal findings. Computed tomography (CT) of the neck with contrast showed a 1.7 cm × 1.4 cm × 2 cm pseudoaneurysm of the left external jugular vein  and 3. TWe found minimal literature on the topic of external jugular vein aneurysm and pseudoaneurysm, with only two other case reports of pseudoaneurysm published. We could not find any articles that had performed a formal review of the literature. The What do we already know about this clinical entity?External jugular venous pseudoaneurysm is a rare presentation. It is rarely symptomatic and often caused by trauma or cannulation of the internal jugular vein.What makes this presentation of disease reportable?Although ultrasound or computed tomography (CT) with angiography is recommended, in this case we demonstrate CT with contrast is sufficient to make the diagnosis.What is the major learning point?Ultrasound is the standard of care imaging modality. If asymptomatic, most pseudoaneurysms can be safely discharged and follow up with vascular surgery as an outpatient.How might this improve emergency medicine practice?Complications are very rare and often not life-threatening and can be managed as an outpatient.The most common presentation for aneurysm and pseudoaneurysm is a pulsatile, palpable mass that enlarges with valsalva.11Ultrasound can show turbulent flow and dilation with 95% accuracy for pseudoaneurysm.Venous aneurysms are classified as primary  and secondary (acquired).3Pseudoaneurysms in the arterial system of the neck have similar underlying etiology to include trauma,12Venous aneurysms and pseudoaneurysms are a rare cause of neck masses.10Complications may include pulmonary embolism, thrombus formation or thrombophlebitis, and rupture.14Surgical indications include large aneurysms compressing nearby structures, potential for thrombus, cosmetic reasons, or presence of symptoms.Pseudoaneurysms of the external jugular vein are very rare with only two other case reports published in the literature. Pseudoaneurysm presents as a pulseless mass that enlarges with valsalva and exertion. No complications have been reported in the literature and no intervention is indicated in the asymptomatic patient. If asymptomatic, patients can be safely discharged with outpatient referral to surgery for cosmetic excision.


Giant/large gallstones have high risk of complications, and technical difficulties during surgery. This case series is the largest ever reported.Case 1: Female (44 years), with one year intermittent right upper quadrant colicky pain. Ultrasound: large gallstone . Elective laparoscopic cholecystectomy (LC): 6 × 4 × 3.3 cm gallstone. Case 2: Female (41 years), presented to emergency room with 3 days right upper quadrant pain/tenderness, vomiting, and positive murphy’s sign. Ultrasound: large gallstone, calculus cholecystitis. Emergency LC: 4.5 × 3.1 × 3.5 cm gallstone. Case 3: Male (38 years), with history of gallstones and acute cholecystitis presented with intermittent right upper quadrant pain (2 months) and vomiting. Normal abdominal examination. Ultrasound: large gallstone. Elective LC: 4.1 × 4 × 3.6 cm gallstone.Gallstones >5 cm are very rare, with higher risk of complications. Gallbladder should be removed even if asymptomatic. Gallstones >3 cm have increased risk for gallbladder cancer, biliary enteric fistula and ileus. LC has challenges that include grasping the gallbladder wall, exposure of Calot’s triangle, and retrieval of gallbladder out of the abdomen. LC appears to be procedure of choice and should be performed by an experienced surgeon, considering the possibility of conversion to open cholecystectomy in case of inability to expose the anatomy or intraoperative difficulties. The sIn the current retrospective single-centre case series at Hamad General Hospital  in Doha, Qatar, we review three consecutive cases of laparoscopic cholecystectomy (2017–2020) for giant gallstones measuring 6 cm, 4.5 cm and 4.1 cm in diameter respectively, all located in the gallbladder and we report them in line with the PROCESS criteria . Patient22.1Sudanese female, 44 years old, non-smoker presented to the general surgery clinic at our institution with one-year history of intermittent right upper quadrant colicky pain related to fatty food, not radiating, and not associated with fever or jaundice. Past medical history was significant for diabetes mellitus type 2 managed by oral hypoglycemic agents. She had no previous surgeries. There was no history of hemolytic disease. On examination, vital signs and abdominal examination were unremarkable. Investigations showed that white blood cells count and liver function tests were all within normal limits. Ultrasound of the abdomen showed normal gallbladder with no features of calculus cholecystitis, but with a single large gallstone (approximately 6 cm). The patient was diagnosed as biliary colic and was admitted for elective LC under general anesthesia. She was placed in the supine position, and a trans-umbilical camera port was inserted in addition to another 3 working ports. Intra operatively, there was some adhesions between the gallbladder and duodenum which were released by endoscopic scissors. The gallbladder wall was thick and the gallstone occupied almost all of Hartmann’s pouch which rendered grasping the gallbladder difficult. After identifying Calot’s triangle and clipping the cystic artery and duct, the gallbladder was dissected from the liver bed, put in an endobag and removed out after extension of the trans umbilical incision. The procedure was undertaken by an experienced laparoscopic general surgeon. The gallstone measured 6 × 4 × 3.3 cm. Post-operative course was uneventful and the patient was discharged home after 1 day. Post-operative histopathology showed chronic cholecystitis with intestinal metaplasia and cholesterolosis. The patient was followed up after two weeks, where she had no active complaints.2.2Filipino female, 41 years old, non-smoker presented to the emergency department at our institution with a three-day history of right upper quadrant abdominal pain associated with multiple episodes of vomiting. The pain was not radiating and not associated with fever or jaundice. No history of chronic illnesses and no previous surgeries, and no history of hemolytic disease. On examination, she had severe right upper quadrant tenderness and positive Murphy’s sign. Liver function tests were all within normal limits, but white blood cells count was elevated . Ultrasound of the abdomen showed large calculus within the gallbladder measuring about 4 cm with mild sludge, thick wall and pericholecystic fluid suggesting calculus cholecystitis. Patient was diagnosed as acute cholecystitis and admitted for emergency LC under general anesthesia, placed in supine position, a supra umbilical camera port was inserted in addition to another 3 working ports. Intra operatively, there was severe inflammation in which the omentum and hepatic flexure of the colon had formed a mass adherent to the gallbladder. The mass was dismantled using blunt dissection, gallbladder wall was thick and edematous, and the gallstone occupied almost all of Hartmann’s pouch. By milking the gallstone up towards the fundus, it was possible to hold Hartmann’s pouch and start the dissection. After identifying Calot’s triangle and clipping the cystic artery and duct, the gallbladder was dissected from the liver bed, put in an endobag, and removed out after minimal lateral extension of the supra umbilical incision. The procedure was undertaken by an experienced laparoscopic general surgeon. The gallstone measured 4.5 × 3.1 × 3.5 cm. Post-operative course was uneventful and the patient was discharged after two days of surgery. Post-operative histopathology showed acute cholecystitis. The patient was seen after two weeks, she had no active issues.2.3Filipino male, 38 years old, non-smoker, presented to the general surgery clinic at our institution with intermittent right upper quadrant pain since two months radiating to the right shoulder and associated with vomiting. He had history of gallstones and a previous episode of acute cholecystitis 6 months prior that was treated conservatively. No past medical or surgical history, and no history of hemolytic disease. On examination, he had normal vital signs, and no abdominal tenderness. Ultrasound of the abdomen showed a distended gallbladder with thick wall and large calculus (about 5 cm), with few sludge balls. No evidence of pericholecystic fluid or cholecystitis. Patient was diagnosed as chronic cholecystitis and admitted for elective LC under general anesthesia. At surgery, he was placed in supine position, and a supra umbilical camera port was inserted in addition to another 3 working ports. After entrance to the peritoneal cavity, there were adhesions between the greater omentum and gallbladder. Gallbladder was distended with thick wall. As there was a dilated cystic duct that raised suspicion of common bile duct stone, an intraoperative cholangiogram was undertaken, which showed a filling defect in the distal part of the common bile duct without obstruction, and there was passage of contrast into the duodenum. Using a Dormia basket, the sludge and tiny stones were extracted from the common bile duct. A second (check) cholangiogram was then done that confirmed the smooth passage of contrast to the duodenum without any filling defect. After dissection of the gallbladder, it was put in an endobag and removed out after minimal lateral extension of the supra umbilical incision. The procedure was undertaken by an experienced laparoscopic general surgeon. The gallstone measured 4.1 × 4 × 3.6 cm. Post-operative course was smooth without any complications. Patient was discharged one day after surgery. Histopathology showed xanthomatous chronic cholecystitis. At follow up two weeks later, he had no active complaints.3We report a case series of three patients with giant gallstones. To the best of our knowledge, this is largest case series of giant gallstones ever reported in the literature. All three cases were laparoscopically managed, and their post-operative courses were uneventful with no complications.As for demographics, gallstones are more common in women, especially during their fertile years, probably due to increased estrogen levels which may increase cholesterol in the bile and decreased gallbladder movement, resulting in gallstone formation ,2,11. OuIn terms of associated comorbidities, dyslipidemia and diabetes mellitus are considered important associated comorbidities and risk factors for developing gallstones . In suppAs for presentation, 60%–80% of gallstones are asymptomatic , frequenIn connection with imaging, ultrasonography (US) is the method most often used to detect cholelithiasis and cholecystitis (90–95% specificity and sensitivity), can detect and accurately assess stone size as small as 2 mm, show thickening of the gallbladder wall, and should be routine ,19. US hIn terms of size, we agree with others that consensus is required to ascertain the measurements to be used to define a gallstone as giant or large . Based oIn terms of treatment, most gallstone patients remain asymptomatic and can be managed with watchful waiting . AsymptoFor symptomatic gallstones, LC has become the management of choice . For giaAs for the surgical technique, giant gallstones could result in severe inflammation, adhesions and thickening of the gallbladder wall, where adhesions is an important reason for conversion of laparoscopic to open cholecystectomy . In addiAnother consideration is the site and manner of retrieval of the gallbladder out of the abdomen after cholecystectomy. As regards to site, we removed the gallbladder through the 10 mm camera port after minimal extension of the incisions. In Case 1, the camera port was trans-umbilical, while in the other two cases it was supra-umbilical. Even after extension of the incision, we believe that the supra-umbilical/ trans-umbilical retrieval approach results in better cosmetic appearance in terms of wound scar, supporting previous reports . To the As regards to long term complications of large gallstones, gallstones > 3 cm have a 10.1 relative risk for the development of gallbladder cancer, compared to patients without gallstones ,25. HencIn terms of post-operative histopathology, we found chronic cholecystitis in two patients, and acute cholecystitis in one. This case series has limitations. Information on the composition of the each of the three stones would have been beneficial for the better understanding of the pathophysiology. Further research could explore the composition of giant stones in an attempt to better understand the underlying etiology of giant gallstones. Despite this, the current case series has strengths, as to the best of our knowledge, this is the largest case series of giant gallstones reported, and that it is accompanied with a thorough literature review outlining similar cases elsewhere.4Giant gallstones are associated with high risk of complications and LC is warranted in symptomatic and asymptomatic patients. Even for giant gallstones, LC appears to be the primary procedure of choice over open cholecystectomy and should be performed by an expert laparoscopic surgeon, taking into consideration the possibility of conversion to open in case of inability to expose the anatomy and any intraoperative technical difficulties.Nothing to declare.Nothing to declare.Approved by Medical Research Center, Hamad Medical Corporation reference number (MRC-04-20-323).Verbal informed consent (in presence of a third witness) was obtained from the patients for publication of this case series and accompanying images. This is available for the Editor-in-Chief of this journal on request.Mohammad Al Zoubi: data collection, data interpretation, writing the paper. Walid El Ansari: study concept, data interpretation, writing the paper. Ahmed Al-Moudaris: data interpretation, reviewing the paper. Abdelrahman Abdelaal: study concept, data interpretation, editing the paper. All authors read and approved the final version.Not first in Man.welansari9@gmail.com.Walid El Ansari: Not commissioned, externally peer-reviewed.


Utilization of the Hotz‐Celsus technique with standing sedation and local nerve blocks in cattle provides adequate correction of cicatricial entropion. Utilization of the Hotz‐Celsus technique with standing sedation and local nerve blocks in cattle provides adequate correction of cicatricial entropion. They were both found to be suffering from trauma‐induced cicatricial and spastic entropion which led to corneal ulceration in both cases. Due to the lack of response to tacking sutures and the appearance of the wounds, both received a Hotz‐Celsus repair. There are few reports of surgical entropion correction in cattle in the current veterinary literature. Utilization of the Hotz‐Celsus technique with standing sedation and local nerve blocks provided adequate correction of cicatricial entropion in both cases. Surgical repair is described in detail in order to provide a framework for practitioners to perform this surgery.Entropion is inversion of the eyelids and is common in many species. It typically results in trichiasis, blepharospasm, and excessive lacrimation. This condition is rarely diagnosed in cattle.Correcting entropion is important in any species due to the discomfort for the animal and the potential to cause severe, persistent, or recurrent corneal ulcers which can lead to corneal perforation, severe corneal scarring, and loss of vision or the globe. Ocular pain caused by corneal ulceration can affect both production and reproduction in food animals because of decreased vision and comfort.2A 2‐year‐old Brahman bull presented to the Mississippi State University Animal Health Center for a 2‐week history of epiphora and blepharospasm in the right eye (OD). The client observed him rubbing his head on wooden posts in the pasture prior to the recognition of clinical signs. One week prior to presentation, the referring veterinarian diagnosed the bull with keratoconjunctivitis. The bull was administered two injections of oxytetracycline  (20 mg/kg SQ q72h). After failure to respond to treatment, the bull was referred for further evaluation.On presentation, vital parameters were within normal limits. Blepharospasm and excessive lacrimation were present in the right eye (OD). Periocular blepharedema was present OD. Vision was present in both eyes (OU) with normal pupillary light reflexes, palpebral reflexes, and menace responses.Proparacaine  was applied OD to provide analgesia and facilitate a thorough ophthalmic examination. Complete resolution of the entropion after application of topical anesthetic did not occur, supporting that entropion was more than just spastic in nature. A thickened, scarred vertical segment of skin was noted at the lateral aspect of the inferior palpebral margin causing displacement of the eyelid margin toward the globe, which suggested cicatricial entropion. Figure  AdditionThe history and ophthalmic examination suggested that an eyelid wound had healed with scarring. This wound contracted, bringing the eyelid into closer association with the globe, which led to trichiasis causing a corneal ulcer. Entropion worsened due to severe blepharospasm and spastic entropion, which caused the corneal ulcer to persist.After the initial examination, two horizontal mattress tacking sutures were placed using #2 Braunamid  in the inferior palpebra OD to retract the eyelid margins from the cornea to temporarily relieve trichiasis and allow the ulcer to heal. Atropine Sulfate 1% ophthalmic ointment  was given every 24 hours for cycloplegia to control pain related to corneal ulceration and reflex uveitis. Triple antibiotic ophthalmic ointment containing bacitracin, neomycin, and polymyxin B  was started every 8 to 12 hours to provide broad‐spectrum antibacterial protection. A 1.1mg/kg dose of flunixin meglumine  was administered once intravenously for pain and inflammation. Epiphora and blepharospasm continued the next morning, indicating that the temporary tacking sutures were insufficiently retracting the eyelid.After removal of the tacking sutures, a third eyelid flap was placed OD using #2 Braunamid to protect the ulcer from trichiasis. Atropine and triple antibiotic ointments were applied once prior to placement of the flap. Meloxicam  was started for continued pain management at a tapering dose of 1mg/kg PO every 24 hours for 3 days followed by 0.5mg/kg orally every other day for 3 doses. Oxytetracycline was given at 20 mg/kg subcutaneously on the day of presentation and day three of hospitalization.The third eyelid flap was removed one week later. Fluorescein stain defined the ulcer diameter as approximately 2 × 2 mm at that time. Because the ulcer and significant entropion were still present, standing sedation  was used to perform a Hotz‐Celsus surgery on the inferior palpebra. The bull was placed in a hydraulic chute with halter tied to the head plate for restraint. The eyelashes were trimmed, and the eyelids were prepared with dilute (1:50) iodine solution and saline. An auriculopalpebral nerve block and a line block 2‐3 mm inferior to the eyelid margin were performed using 2% lidocaine  to provide lack of sensation and akinesia of the right inferior eyelid  was administered subcutaneously once.One week later, the wound had healed, but cicatricial entropion of the inferior palpebra was present. Three temporary tacking sutures were placed to externally rotate the eyelid margin, with the goal of causing scarring that would lead to permanent rotation. The sutures were removed ten days after placement because tissue reaction of the subcutaneous tissues felt adequate to ensure appropriate scarring. The entropion immediately recurred after removal of tacking sutures.A Hotz‐celsus procedure was performed on the inferior palpebra. For this procedure, the patient was heavily sedated  and placed in lateral recumbency. A line block with 2% lidocaine  was performed along the proposed incision. An elliptical segment of epidermis and superficial dermis, approximately 4 mm in diameter, was removed from the inferior palpebra just ventral to the eyelid margin. The resulting defect was closed using 0 PDS suture in a simple interrupted pattern. No tarsorrhaphy was performed because corneal ulceration was not present and there was no evidence of spastic entropion. Sutures were removed two weeks postoperatively with no recurrence noted.4The cases presented here provide detailed examples of clinical management of cattle with entropion. Both cases had cicatricial entropion that occurred from previous injury to the eyelid which has not been reported in this species. In both cases, temporary tacking and relief of spastic entropion did not correct the underlying problem, necessitating permanent surgical repair. Because entropion is rarely reported, there is little comprehensive information available on surgical options in cattle.There are important considerations when selecting an entropion repair technique in any species. If a corneal ulcer is present, it is preferable to temporarily resolve spastic entropion prior to surgical repair to avoid the risk of creating ectropion through overcorrection.The Hotz‐Celsus technique is the most common surgery used for permanent repair of entropion. This technique involves removal of an elliptical portion of skin adjacent to the eyelid margin in order to roll the eyelid away from the cornea. In the past 10‐15 years, wedge resection combined with the Hotz‐Celsus or lateral canthal closure techniques have been recommended in canine and feline entropion to reduce the likelihood of overcorrection or need for a second surgery.There are many suture choices for entropion repair; polyglactin, nylon, and silk have all been recommended.Major considerations for entropion correction in cattle are the ability to safely handle the animal for surgery and ability to give medications. This is affected by the accessibility of the animal on the farm, the veterinary/care facilities available, and availability of skilled personnel. The cases presented here were hospitalized at a teaching hospital, allowing for safe medication administration and close monitoring. This was a major advantage that likely contributed to success. Both cases healed within 7‐10 days.Injections of various substances have been reported for entropion repair in sheep, dogs, and cats.Both animals in this case report healed with little morbidity after their repair. The entropion was not overcorrected even though spastic entropion and corneal ulceration were still present prior to permanent surgery. There were no postoperative complications, and the entropion has not recurred in either case in the year since treatment.5We confirm that the manuscript was read and approved by all authors. We confirm that the order of authors has been approved by all authors and that no other authors satisfied the criteria for authorship. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication. All owners signed informed consent for procedures deemed necessary upon hospitalization for the animals in this case series.There are no conflicts of interest for any authors for this manuscript.Meghan R. Villers: was the student assigned to the Brahman bull case and originally wrote the case report on the bull for a school project; Gretchen P. Grissett: was the clinician in charge of both cases, wrote the case of the 6‐month‐old bull, and edited the manuscript; Mary R. Telle: provided vital editing of manuscript and research on appropriate journals for case reviews; Caroline M. Betbeze: is the corresponding author, consulted on both cases, performed the surgery on the Brahman bull, wrote the discussion portion of the manuscript, provided extensive editing of manuscript, and submitted the manuscript.


Abdominal symptoms in patients with hematological malignancies can occur due to an array of pathologies. Two diagnoses with similar presentation albeit, generally opposite treatment modalities, are typhlitis (inflammation of cecum) and acute appendicitis. Both diagnoses have to be kept in mind in such a patient presenting with right lower quadrant (RLQ) pain. Sagacious clinical judgment along with the aid of radiological imaging may help in differentiating between the two conditions. We present a case of a young male with chronic myeloid leukemia (CML) on imatinib, diagnosed and started on therapy four years earlier, who presented with symptoms of RLQ pain not typical of acute appendicitis. The accurate diagnosis was made with the assistance of ultrasound (US) imaging and prompt surgical therapy was instituted followed by a smooth postoperative recovery. Acute appendicitis is one of the most common reasons for emergent hospital admissions worldwide with a lifetime risk reaching up to 8% in the general population . HoweverA 28-year-old male diagnosed with chronic myeloid leukemia (CML) in December 2014 and started on imatinib, presented to the ED with two days history of abdominal pain, initially generalized but eventually shifting to the right iliac fossa. This was associated with the passage of loose watery stools although he did not have nausea, vomiting, or loss of appetite. He was afebrile with a heart rate of 80 beats per minute and normal blood pressure of 115/70 mmHg. He was a thin and lean person with a BMI (body mass index) of 22. On examination, he displayed right iliac fossa tenderness with rebound tenderness. His white blood cell count was 6.10 x 103/uL while the absolute neutrophil count was 3.3 x 103/uL, hemoglobin was 15 g/dL, and platelets were 240/mm3; however, C-reactive protein level was mildly elevated, i.e. 39 mg/L . His Alvarado score was only two showing appendicitis as an unlikely diagnosis. However, his ultrasound (US) examination of the abdomen revealed a 13 mm x 7 mm blind-ending tubular structure distended with fluid at the right iliac fossa impressive of an obstructed inflamed appendix  and a laparoscopic appendectomy was performed. Intraoperative findings were remarkable for an obviously inflamed appendix without any perforation or pus in the abdominal cavity. He had a smooth postoperative course during which antibiotics were continued. He was discharged the following day on oral antibiotics. He was seen two weeks later and was doing well. Histopathological examination confirmed the diagnosis of acute appendicitis.Acute appendicitis is one of the most common surgical emergencies worldwide with an incidence of up to 8% in the general population . HoweverAtypical presentation of acute appendicitis may lead to delay in diagnosis and increases the likelihood of grave complications like perforation, local or generalized peritonitis, and sepsis . The symTyphlitis or necrotizing enterocolitis is a condition commonly affecting the cecum in neutropenic patients such as those with hematologic malignancies especially on cytotoxic chemotherapy . The patGiven the similar clinical presentation of both entities, reaching an accurate surgical diagnosis is pertinent to be able to initiate the appropriate therapy at the earliest. Our patient did not present with the typical symptoms of anorexia, nausea, or vomiting and had a normal white blood cell count with only a slightly elevated C-reactive protein (CRP) level (Alvarado score of 2). The presence of watery stools would add to the confusion; however, we were able to accurately diagnose acute appendicitis with the assistance of an US examination. Ultrasonography is generally regarded as a first-line diagnostic test in acute appendicitis and has shown to have a sensitivity and specificity of 86% and 81% respectively . In typhPhysicians should be aware of the complexities abound in patients with hematological malignancies and keep in mind all the possible differential diagnoses in such individuals who present with abdominal pain. Accurate clinical acumen aided by radiological imaging is required to decide on the appropriate path of management. The CT abdomen can delineate many possible pathologies in the right iliac fossa. When in doubt and in patients who may be deteriorating a diagnostic laparoscopy may be warranted.


Omental infarction and epiploic appendagitis are rare causes of acute abdominal pain in the pediatric population. Radiological evaluation is necessary to establish a specific diagnosis and to differentiate appendicitis from these conditions as they can be often managed conservatively without surgical intervention. Abdominal pain is a common complaint in children presenting to emergency department. The differential diagnosis includes serious surgical pathologies.Omental infarction (OI) and epiploic appendagitis (EA) are included in primary abdominal fat necrosis and are rare causes of abdominal pain in children ,2,3; becEarly identification by imaging studies may prevent unnecessary surgical procedures ,5.We report two cases of primary abdominal fat necrosis, aiming to spread awareness to physicians regarding the clinical presentation and management of this unusual cause of pediatric acute abdominal pain. A review literature was performed.A previously healthy 12-year-old boy presented to our pediatric emergency department with an abrupt onset of colic pain in the right flank and inguinal fossa. There were no other associated symptoms.On examination, he was afebrile with normal vital signs. He was well-hydrated and had neither mouth ulcers nor conjunctival icterus. His weight, height and body mass index were 60 kg, 150 cm and 26.6 (overweight range), respectively. Cardiovascular and respiratory examinations were normal. The abdomen was soft with mild and diffuse tenderness on deep palpation in the right abdominal quadrants but without rebound tenderness or guarding.Abdominal ultrasonography (US) and the laboratory work-up were unremarkable. Therefore, the patient was elected to conservative treatment with an oral non-steroidal anti-inflammatory drug at home.However, two days later the patient returned to the emergency department describing his abdominal pain as persisting despite medication. The laboratory work-up was unremarkable with only a mildly increased level of serum C-reactive protein (42.9 mg/L).A repeat US was inconclusive of acute appendicitis and a computed tomography (CT) scan was requested as a second-line diagnostic imaging tool. This revealed a hyperechoic mass below the liver with an area of approximately 6 cm (maximum diameter) of reticular infiltration of the omental fat. The CT scan well characterized the fatty nature of the lesion and was highly suggestive of OI .The patient was discharged home with an oral anti-inflammatory therapy for five days and, at six months follow-up, he remains symptom free.A 16-year-old previously healthy girl presented to the pediatric emergency department with a one-day history of worsening abdominal pain. Her body mass index was normal. She described the pain as aching in character, occurring intermittently several times a day, lasting for several hours and localized to the right and left lower quadrant. No triggering or alleviating factors were identified including eating and defecation. The only associated symptom was nausea. On physical examination, she was afebrile with normal vital signs. She was well-hydrated and had neither mouth ulcers nor conjunctival icterus. Cardiovascular and respiratory examinations were normal. The abdominal examination was significant for tenderness to palpation in the lower quadrants. There were normal bowel sounds and hepatosplenomegaly was not present. The laboratory tests were normal.An abdominal US was performed and a diagnosis of EA was rendered. A fat-attenuated nodular lesion measuring 1.3 cm in diameter was observed anterior to the cecum . The appThe patient was managed conservatively with an oral anti-inflammatory therapy and she was discharged home; her symptoms resolved over 48 h with a return to a full regular diet. She was seen in follow-up two weeks after discharge from the hospital and she remained asymptomatic. She has had no recurrence of abdominal pain in the eight months since hospitalization.OI and EA are included in primary abdominal fat necrosis and are rare causes of abdominal pain in children.Although the first report of OI was in 1896 by Bush , there aOmentum is a fold of peritoneum that has a protective function for the intestinal tract in case of inflammations or injury. OI is a rare pediatric condition; it accounts for approximately 15% of all cases reported  and it oEpiploic appendages are small fat tissues located on the antimesenteric surface of the colon on the teniae. They are pedunculated and present on the entire length of the colon except the rectum where they are absent. Their size ranges from 0.5 to 5 cm with the largest ones located near the sigmoid colon and cecum. Their exact function is still unknown; probably, they have a protective function for the colon.Like OI, EA occurs with torsion or thrombosis of arterioles feeding the appendages. It is a rare condition in the pediatric population without sex predilection . In adulPrimary abdominal fat necrosis is an uncommon cause of non-specific abdominal pain and is commonly described as acute in onset and steady in character. In epiploic appendagitis, associated manifestations are sporadic such as nausea, vomiting, anorexia and fever but they are reported in 50% of the cases of OI . In our The non-specific clinical findings cause confusion at the diagnosis. Appendicitis, acute cholecystitis and, in adult patients, diverticulitis are the most frequent misdiagnoses.In EA, the pain is localized in the affected area; it is most frequent in the lower left quadrant (76%) followed by the right lower quadrant (20%) . In factA physical examination can mimic an acute abdomen; however, a lack of elevation in inflammatory markers or fever is suggestive of a more benign process. Neutrophilia can be detected in two-thirds of cases of OI .Before the widespread use of US and CT scans, EA and OI were most commonly diagnosed at surgery. The advent of modern sophisticated imaging tools has significantly decreased the number of unnecessary surgical explorations and allowed an easier diagnosis of these conditions. However, in the last 20 years, up to 32% of cases of OI and 19% of EA are diagnosed intra-operatively, as indicated in US, CT scans and MRI can be used in the diagnosis. Both conditions present very similar imaging. OI is larger in size (3.5–7.0 cm) .On US examination, which are often used to evaluate abdominal pain in children, EA is seen as a non-compressible hyperechoic mass adjacent to the colon wall with an absence of color flow on a Doppler. If the mass is within the omentum or adheres to the abdominal wall, it is a case of OI. In this case, the increased vascularity can be detected around the lesion on the color Doppler valuation due to the surrounding inflammatory reaction .In our institution, US is the first imaging method used for suspected appendicitis; however, in the case of an equivocal study, a CT scan is performed.On a CT scan, normal epiploic appendages are not seen. EA results are seen like an antimesenteric fat mass with hyperdense rim, adjacent fat stranding, a thickening of the colon wall and a specific central dot sign, which represents the central high attenuation due to the thrombotic vascular structure in the center of the epiploic appendages . CT is tMRI is not a well-studied imaging modality for EA or OI; however, findings are similar to a CT scan. EA is seen like a mass on the colon wall; the central portion is hyperintense on T1- and T2-weighted images, the peripheral rim is hypointense on T1- and T2-weighted images and the central dot sign appears hypointense on T2-weighted images. Absence of this sign does not eliminate the possibility of EA but the presence is a specific indicator of the pathology .MRI permits the avoidance of the potential side effects of ionized radiation exposure but the low possibility of performing this exam in an emergency department and the higher cost play against the application of MRI for a differential diagnosis. A CT scan is the most widely used abdominal imaging adopted in an acute setting.The clear disadvantages of US include that is operator-dependent, it is limited by large amounts of bowel gas and the images provided cannot always be readily interpreted by clinicians. On the other hand, the major disadvantage of a CT scan is its use of ionizing radiation.Diagnostic imaging plays an important role in determining whether the disease should be surgically or medically treated. In our pediatric department, we promote the use of US, keeping EA and OI for the differential diagnosis of acute abdominal pain so that the US signs can be acknowledged. Only if there are doubts do we use second level exploration such as a CT scan. In the pediatric patient, US is the imaging of choice as it avoids the risk of ionizing radiation.In our cases, the first approach was US examination, which was diagnostic in the case of EA and a combination of US and a CT scan was used in the case of OI.EA and OI are benign, self-limiting conditions; it can be difficult to distinguish these diseases but in both situations, the management is the same. When the diagnosis is certain, they can be treated conservatively with intravenous fluids, analgesics and non-steroidal anti-inflammatory treatments. The use of antibiotics have been discussed, mainly in OI. The clinical symptoms usually resolve within two weeks and CT findings resolve after more than six months ,18.In the review performed, the management was conservative in 60% and 36% of EA and OI, respectively . We undeA few authors support early operative management in OI, described as associated with a faster recovery, better pain control and prevention of complications such as abscesses and even sepsis if a necrotic segment of omentum is left in the abdomen . In our Complications of EA and OI are rare and include adhesions, abscess formation, peritonitis, bowel obstruction, intussusceptions or intraperitoneal loose body. In this case, such as in the case of uncertain diagnosis or recurrence, surgical intervention is necessary; in this case, a laparoscopic approach is preferred ,19. No cAlthough EA and OI are usually seen in adults, they are a rare cause of acute abdominal pain in the pediatric population. They should be considered in the differential diagnosis of acute or recurrent right lower quadrant pain in children.The diagnosis of OI and EA is challenging and in the pediatric population US is the imaging of choice as it avoids the risk of ionizing radiation. Considering these conditions, the differential diagnosis has the potential to decrease the number of CT scans because of the benign nature of the disease. CT scans should be reserved only if the US result is negative or inconclusive. Identifying a normal appendix by imaging is fundamental in this scenario.A high index of suspicion and an early identification of primary abdominal fat necrosis appears to prevent unjustified surgical procedures in children.