It is recognized that IDH mutation negative, low-grade epilepsy associated tumors (LEAT) can show diffuse growth patterns and lack the diagnostic hallmarks of either classical dysembryoplastic neuroepithelial tumors (DNT) or typical ganglioglioma. “Nonspecific or diffuse DNT” and more recently “polymorphous low-grade neuroepithelial tumor of the young” have been terms used for these entities. There are few reports on the MRI recognition of these diffuse glioneuronal tumors (dGNT), which is important in planning the extent of surgical resection. In 27 LEATs T1, T2, FLAIR, and postcontrast T1 MRI were evaluated and the pathology reviewed, including immunostaining for NeuN, CD34, MAP2, and IDH1. Each case was then independently classified by pathology or MRI as simple DNT, complex DNT, or dGNT. There was agreement in 23/27 . In 4 cases, there was discrepancy in the diagnosis of simple versus complex DNT but 100% agreement achieved for dGNT. DNT showed significantly more expansion of the cortex, cystic change and ventricle extension than dGNT. dGNT showed significantly more subcortical T2w hyperintensity and focal cortical atrophy which correlated on pathology with CD34 expression, cortical neuronal loss and white matter rarefaction. There was no distinct cortical dysplasia component identified by MRI or pathology in any case. This study highlights that dGNT can be reliably discriminated on MRI from DNT. Dysembryoplastic neuroepithelial tumors (DNT) and gangliogliomas are the most frequent types of long-term epilepsy-associated tumors (LEATs) encountered in epilepsy surgical series , 2. CommRAS–RAF–MAPK and PI3K–AKT–mTOR pathways linking this group of tumors . We included cases with a histological diagnosis of DNT or LEATs with diffuse growth patterns from 2008 to 2014 where there was consent for research and where optimal pre-operative imaging was available for review. This included availability of the following sequences acquired with 1.5 T or 3 T MR scanners: Sagittal , axial , coronal , and T1 MPR (multiplanar reconstruction) sagittal 1 mm reformatted in axial and coronal plane. We did not include other glioma types in patients without refractory epilepsy and we did not include series of typical gangliogliomas or pediatric gliomas. This selection process resulted in a final group of 27 cases available to study . In 19/2IDH1, Ki67 and molecular pathology studies including 1p/19q analysis, BRAF fusion, BRAF V600E mutation, and ATRX mutation (The pathology macroscopic images and histology was reviewed for each case by one neuropathologist (M.T.) on all available histological slides including hematoxylin and eosin (H&E), Luxol fast blue/cresyl violet, and available immunohistochemistry stains including NeuN, neurofilament , MAP2, synaptophysin, CD34, mutation  Table S1mutation  Table S2mutation  and for The MRI were then evaluated in a two-step process blinded to the pathological diagnosis: First, the presence or absence of 25 specific features in each case was recorded. These included location, size, shape, margins, cysts, calcification, hemorrhage, enhancement pattern, bone remodeling, signal intensity, peri-lesional signal change, contact with the ventricles, multi-gyral involvement, cortical expansion, or atrophy  Table S2A comparison between the MRI derived diagnosis and the neuropathological gold standard was performed and the frequency of each of the MR features in each of the 3 tumor entities was established. Statistical analysis using SPSS  was carried out to compare the level of agreement between radiological and pathological diagnosis. Significant differences in the presence of each radiological criteria between tumor groups were assessed to evaluate the relative specificity of MRI features in discriminating dGNT from DNT types. In addition, correlation between MRI and pathology features was carried out.IDH1 mutation, and in 6 cases where ATRX mutation had been evaluated, this was not present. Ten cases were investigated for 1p/19q chromosome LOH as part of the routine work-up but this was not present in any. Analysis for BRAF V600E mutation, however, was confirmed in 5/11 dGNT compared with 0/5 complex DNT and 0/3 simple DNT; this included 1/3 cases of dGNT with focal aggregates of ganglion cells (see below).The pathology review diagnosis confirmed simple DNT in 6 cases, complex DNT in 8 cases, and dGNT in 13 cases . MoleculTwenty-two tumors were located in the temporal lobe, 2 in the frontal, 2 in the parietal and one in the occipital lobe . The MRIFeatures that more significantly associated with dGNT was evidence of ill-defined subcortical white matter T2-w hyperintensity, present in all cases , the presence of bone remodeling (p < 0.01), multi-cystic or “bubbly” appearance (p = 0.001), well-defined lesions lacking abnormal surrounding signal change (p < 0.001) and close contact or “tail-like” extension toward the ventricle (p < 0.05); the latter being a finding in 63% of complex DNT .In 4 dGNT (cases 15–18), aggregates of atypical ganglion cells were also noted on histology as a minor component, suggestive of focal gangliogliomatous differentiation  but no sNineteen of the twenty seven cases had been followed up pre-operatively with a second MRI, the interval period ranging from 1 to 80 months. None of the simple or complex cases showed a change in appearance. However, 3 of the diffuse cases showed change in size and appearance; one showed further atrophy while 2 showed an increase in size.In this study of a series of operated LEATs, we have shown good agreement between pathology and MRI diagnosis. We have identified MRI features that associate with dGNT to enable its distinction from the typical forms of DNT. In particular, the presence of peri-lesional signal changes and cortical atrophy within the tumor zone were MRI features that were frequent in dGNT and correlated with cortical laminar neuronal loss and white matter rarefaction in the region of diffuse tumor infiltration. Although some MRI features in typical DNT may be indicative of its underlying developmental origin, as the ventricular extension “tail sign,” accompanying FCD was not confirmed by MRI or pathology in this LEAT series.There have been relatively few published studies directly correlating MRI with pathology in DNT and DNT-like lesions. Campos et al retrospectively evaluated a series of 61 simple and complex DNT . They coFGFR1 (BRAF V600E gene mutations than DNT and methylation cluster analysis (We showed 100% agreement between the MRI and histology diagnosis of dGNT, supporting its distinction from conventional DNT within the LEAT tumor group. The only previous MRI/pathology correlative study of diffuse LEAT tumor types noted their poor-delineation on MRI with grey-white matter blurring, subcortical signal changes and frequent location in mesial temporal lobe ; this MRFGFR1 , 24 and analysis , 25, 26.analysis .In the current study, the most frequent MRI features of dGNT were peri-lesional T2 signal change and cortical atrophy within the tumor zone; these correlated with degenerative features on pathology, including cortical laminar atrophy and white matter rarefaction with axonal and myelin loss. These superimposed “atrophic” features could be an effect of the seizures themselves or attest to the slow growth rate and long-standing nature of the dGNT and is in keeping with the documented accumulation of degenerative changes reported, including TDP43, tau and p62 . We failThe advances in the molecular characterization of LEATS, as well as providing diagnostic and prognostic biomarkers, will undoubtedly herald a future of individualized treatment plans including tailored surgery . The accSupplementary DataClick here for additional data file.


Dermoid cysts (DCs) are rare benign, epithelial-lined lesions. Up to 7% of them are found in the head and neck region and 80% of those predominantly occur in the orbit, in the nose, and in the floor of the mouth. The average age of presentation is around the age of six. Dermoid cysts located in the parotid gland have only been published in 19 cases so far. Interestingly, the mean age of occurrence in the parotid gland was much higher (31 years). We report on a four-year-old girl being the youngest patient who had ever been diagnosed with this disease.  A dermoid cyst (DC) is defined as a closed, epithelium-lined cavity in the body that contains differentiated tissue and structures like hair, fluid, teeth, or skin glands . DermoidA four-year-old girl was presented to our clinic with a 2-year history of a swelling of her left preauricular region. She did not complain of any prior disease, surgery, or trauma related to this region. The girl was otherwise healthy, with fever, lymphadenopathy, or weight loss being denied.On physical examination, a painless, firm, and nonfluctuant mass was palpable in the area of her left parotid gland. Facial nerve function was normal on both sides. Ultrasonography showed a well-defined, homogenic, round, and hypodense mass with a measured diameter of 2.5 cm . The masTherefore, as the mass did not meet any criteria of malignancy in ultrasonography and MRI, we did not perform a fine-needle aspiration cytology (FNAC). A tumor resection was completed with a partial, superficial parotidectomy under continuous facial nerve monitoring. Intraoperatively, the tumor had a tight capsule without abnormal vascularization  and it wPathological examination showed a benign cyst with lining of squamous cell epithelium and associated skin appendages as it is typical for dermoid cysts. The lumen of the cyst contained several coreless squamous cells and keratin debris. The wall of the cyst contained fibrocartilaginous tissue with mild lymphocyte infiltration . An infiIn summary, the histology confirmed the diagnosis of a dermoid cyst. Postoperatively, the patient did show neither any facial nerve impairment nor any signs of recurrence in our follow-up.Only 7% of all dermoid cysts (DCs) are seen in the head and neck region and most of the children are about six years old at the time of diagnosis. Around 80% of DCs in the head and neck area are to be found in the orbit, nose, and floor of the mouth . Few casLike other benign tumors of the parotid gland, DCs do not cause any specific symptoms and stay asymptomatic until they cause pressure-induced or cosmetic problems. Radiological imaging may guide the way. Ultrasound typically shows a well-circumscribed tumor with mixed or pseudosolid density . An MRI In addition, there are several possible differential diagnoses, including lipoma, lymphoepithelial cysts, fibroma or neurofibroma, blockage of parotid duct, or any kind of benign salivary gland tumor. As first branchial cleft anomalies are another possible differential diagnosis, it is recommended to look carefully for a sinus opening within the external ear canal or around the ear .Although there have been several suggestions for a classification of dermoid cysts in the parotid gland, no agreement exists due to their rarity , 10. WhiChoi et al. attribute DCs of the parotid gland to the third subgroup of the third category, while Yigit et al. hypothesize that these cysts might belong to the second category , 10. TheIndependent of its histopathological categorization, superficial parotidectomy is the standard procedure to remove the tumor. Total parotidectomy is only performed in rare cases of DCs that are located in deeper parts of the parotid gland . Even thDermoid cysts are benign tumors that rarely occur in the parotid gland. Although malignant transformation in the head and neck region has only been described in DCs of the floor of the mouth, they should be completely removed by microscopic surgery under continuous facial nerve monitoring. Preoperative imaging via ultrasonography and MRI or a preoperative fine-needle aspiration cytology can provide diagnostic clues. However the definitive diagnosis can only be confirmed by histopathological examination.


Immature teratoma in a mediastinal location is a rare disease that might present as a valve pathology. Germ cell tumors with mediastinal locations account for up to 6% of immature teratoma cases. We present a case of an immature teratoma located primarily in the anterior mediastinum that manifested solely through symptoms of pulmonary stenosis.We report a case of a 20-year-old white man with an immature teratoma who presented with progressive exertional dyspnea. During a cardiac examination, an ejection systolic murmur was observed, and echocardiography findings at an Emergency Centre revealed high velocity flow at the level of the pulmonary artery, indicating pulmonary stenosis. He was hospitalized in our Cardiology Department for further investigation. A chest X-ray revealed a mediastinal mass, and repeated echocardiography indicated the presence of a large mediastinal mass compressing his main pulmonary artery. Magnetic resonance imaging confirmed the tumor in the mediastinum, and a histopathological diagnosis of immature teratoma was established following biopsy.Immature teratoma causing cardiac-related complaints might shift the diagnosis toward cardiovascular diseases, thus requiring prompt examination by standard and sophisticated methods to clarify the diagnosis. Germ cell tumors account for up to 6% of all mediastinal tumors. They are more common in men and young adults. Common tumors, such as teratomas, are usually located in the anterior part of the mediastinum. They grow slowly, but when they become large they can compress nearby organs and cause symptoms such as dyspnea, chest pain, or coughing , 2. We pA 20-year-old white man, a student, presented to our clinic with a history of exertional breathlessness, non-productive cough, and fatigue over the previous 2 months. He received ambulatory treatment with antibiotics for his cough that was unsuccessful in relieving his symptoms.A physical examination on admission revealed an ejection systolic murmur at the left sternal border with no radiation. His heart rate was 130 beats per minute (bpm), and his blood pressure was 110/60 mmHg. His lung fields, lymph nodes, and testicles were unremarkable during an examination. A neurological examination, routine blood analysis, and urine analysis were approximately within normal ranges. A resting 12-lead electrocardiogram demonstrated sinus tachycardia. A posterior-anterior native chest radiograph indicated mediastinal widening at the level of the pulmonary cone, which is indicative of a mediastinal mass  in the parasternal view revealed a large extracardiac mass that was compressing the pulmonary artery Fig. .Fig. 2TwA continuous wave Doppler examination showed an increased velocity  with a peak systolic gradient of 84 mmHg and a mean gradient of 44 mmHg in the pulmonary artery at the site of compression  of his chest was performed, which confirmed the presence of an anterior mediastinal mass compressing his main pulmonary artery Figs.  and 5.FiThe results of a gonadal examination and scrotal ultrasonography were normal. A biopsy confirmed an immature germ cell teratoma. Histological sections stained with hematoxylin-eosin showed immature mesenchyme as a sparsely cellular, loose, primitive mesenchymal tissue with mitotic figure. In addition, a neuroepithelial component was present in the form of rosettes. Two treatment methods were used due to the long survival periods that can be expected with them: following surgical resection, an appropriate course of chemotherapy in our Oncology department led to a decrease in tumor bulk and an improvement in our patient’s symptoms (dyspnea) during 6-month follow-up. He experienced no symptoms while receiving chemotherapy.Immature teratoma located primarily in the anterior mediastinum might present as a valve pathology manifesting solely through symptoms of pulmonary stenosis.Primary germ cell tumors account for approximately 15% of anterior mediastinal tumors in adults and children . GerminaImmature (germ cell) teratoma is mostly found in men, specifically in the mediastinum (anterior); there, it affects the pulmonary artery flow and causes stenosis. Mediastinal localization is very rare. It is only observed in 1% of all mediastinal teratomas, but mediastinal tumors are generally symptomatic. Thus, patients may present with dyspnea, cough, and chest pain . The phyEchocardiography (Doppler) enables the investigation of cardiac and/or paracardiac structures and may enhance the visibility, as well as the severity, of great vessel compressions . In our Teratomas are commonly classified using the Gonzalez–Crussi grading system: 0, mature; 1, immature, probably benign; 2, immature, possibly malignant (cancerous); and 3, true malignant. In the case of the latter, additional cancer staging applies.The treatment of choice is complete surgical removal. In cases of malignant teratomas, this treatment is followed by chemotherapy. Teratomas that are located in surgically inaccessible locations  are likely to be malignant (late discovery and/or treatment) and are sometimes treated with chemotherapy first , 10.Regarding prognoses, when complete resection is combined with chemotherapy, a long survival period can be expected.Echocardiography is the method of choice for the initial approach in determining the nature of heart murmurs. MRI is a valuable imaging method that complements the diagnosis of infiltrative masses that might cause the compression of cardiac structures and mimic valvular heart disease, thus facilitating further management and a treatment plan.


Abdominal pain is one of the most common presenting complaints at the Emergency Department (ED). Given the myriad of possible differential diagnoses for abdominal pain, it becomes more important to diagnose conditions requiring emergent surgical intervention early. We present a case of an elderly male patient with abdominal pain secondary to perforated hollow viscus, subtle evidence of pneumoretroperitoneum on the initial supine abdominal X-ray, and review the signs of pneumoperitoneum and pneumoretroperitoneum on plain abdominal X-rays. Perforated hollow viscus may result in pneumoperitoneum or pneumoretroperitoneum, depending on the location of perforation along the gastrointestinal tract , 2, and An 85-year-old male presented to the ED with complaints of constipation with no passage of flatus, generalized abdominal discomfort, and abdominal distension for 4 days. His symptoms were progressively worsening over the 4 days. There was a single episode of nonbilious vomiting on the day prior to his ED visit. He had been taking oral tramadol tablets (dose: 50 mg TDS PRN) for pain relief after sustaining a vertebral fracture a month ago. The abdominal discomfort, constipation, and vomiting episode may have been associated with consumption of tramadol tablets. There were no prior episodes of similar symptoms and no identified relieving factors. He did not have any other associated symptoms such as fever, change in bowel habits, or history suggesting gastrointestinal bleeding.His vital signs were as follows: temperature 35.7°C; pulse rate 79 beats per minute; respiratory rate of 17 per minute; blood pressure 125/59 mmHg; pulse oximetry reading of 99% on room air; and pain score of 2/10. On physical examination, the patient was alert and conversant. Hydration was good and he did not appear pale or jaundiced. On abdominal examination, the abdomen was soft without any focal tenderness, there was no rebound, guarding or palpable abdominal mass, abdominal distension was noted, and bowel sounds were present and normal sounding. Renal punch was negative. On digital rectal examination, rectum was empty. Anal tone and perianal sensation were intact.9/L, with neutrophil predominance. Renal panel showed acute renal impairment with elevated urea (18 mmol/L), creatinine (266 umol/L), and decreased bicarbonate (15.9 mmol/L). Laboratory tests were otherwise unremarkable.Full blood count showed slight elevation of white blood cell count 12.6 × 10Erect chest X-ray showed no free air under diaphragm. Supine abdominal X-ray showed no dilated bowel loops, but there was an abnormal lucency at the right abdomen outlining the right crus of the diaphragm and extending along the right psoas muscle . The finCT scan of the abdomen and pelvis was ordered at the inpatient setting for the patient in lieu of the findings on abdominal X-ray. The physical examination findings progressed with time and the patient developed generalized abdominal tenderness and guarding over the epigastrium and right flank region around 11 hours after his initial presentation to the ED. A CT scan of the thorax was also subsequently done to exclude esophageal perforation.CT imaging done showed extensive retroperitoneal gas with mediastinal extension  and therBesides perforated hollow viscus, other more benign causes of pneumoperitoneum include recent abdominal surgery, endoscopic procedures, and peritoneal dialysis . The incSigns of peritonism on clinical examination develop as gastrointestinal contents from the perforation irritate the peritoneum, leading to findings such as guarding and rebound tenderness of the abdomen. When the perforation occurs within and remains restricted to the retroperitoneal space, the presentation may be subtle and atypical, with possible complaints of associated back pain. As with this case presentation, there may not be typical findings of abdominal tenderness or peritonism during the initial stages when pneumoretroperitoneum remains localized.Signs of pneumoperitoneum on abdominal X-ray are more often discussed and highlighted, compared to those signs associated with pneumoretroperitoneum. They include Rigler's sign, hyperlucent liver sign, doge cap sign, falciform ligament sign, urachus sign, football sign, cupola sign, and air under diaphragm . StudiesThe development of positive physical findings on clinical examination was preceded by subtle presentation of pneumoretroperitoneum on abdominal X-ray, hence the importance in recognising the features suggestive of pneumoretroperitoneum on plain radiographs. In patients with initial diagnosis which are indeterminate, serial abdominal examination remains helpful to identify evolving abdominal pathology , especiaThe patient presented with free air in the retroperitoneal space, which communicated superiorly with the posterior mediastinum via the diaphragmatic aortic hiatus and inferiorly to the right iliac fossa at the level, above the right inguinal ligament. Radiological features on X-ray suggestive of pneumoretroperitoneum include air outlining the kidney, psoas shadow, and diaphragmatic crus, usually more common on the right. There may be presence of mediastinal or cervical emphysema –13. The This case highlights the difficulties in diagnosing pneumoretroperitoneum with a supine abdominal X-ray. ED physicians should be familiar with subtle signs of extraluminal air on the abdominal X-ray to avoid delayed diagnosis of a potentially high morbidity and mortality condition.


Colonic complications are rare after acute pancreatitis but are associated with a high mortality. Possible complications include mechanical obstruction, ischaemic necrosis, haemorrhage, and fistula. We report a case of large bowel obstruction in a 31-year-old postpartum female, secondary to severe gallstone pancreatitis. The patient required emergency laparotomy and segmental bowel resection, as well as cholecystectomy. Presentation of obstruction occurs during the acute episode or can be delayed for several weeks. The most common site is the splenic flexure owing to its proximity to the pancreas. Initial management may be conservative, stenting, or surgical. CT is an acceptable baseline investigation in all cases of new onset bowel obstruction. Although bowel obstruction is a rare complication of pancreatitis, clinicians should be aware of it due to its high mortality. Obstruction can occur after a significant delay following the resolution of pancreatitis. Those patients with evidence of colonic involvement on pancreatic imaging warrant further large bowel evaluation. Bowel resection may be required electively or acutely. Colonic stenting has an increasing role in the management of large bowel obstruction but is a modality of treatment that needs further evaluation in this setting. Colonic complications of pancreatitis including paralytic ileus, colonic necrosis, and pancreatic-colonic fistulae have been well described and occur with varying frequency . HoweverA 31-year-old female presented as an emergency to our department with a short history of painful abdominal distension and constipation. She had a recent admission with severe postpartum gallstone pancreatitis. A computed tomography (CT) scan during that admission showed pancreatitis with large bowel dilatation up to the splenic flexure and peripancreatic fluid collections . A subseOn readmission, she was noted to be anxious and clinically appeared dehydrated. Abdominal examination revealed distension with epigastric tenderness and absent bowel sounds. Blood tests were unremarkable. An urgent CT scan confirmed large bowel obstruction with a cut-off at the splenic flexure .At laparotomy, it was noted that the large intestinal obstruction was due to a densely adherent inflammatory peripancreatic mass with surrounding fat necrosis. A segmental colonic resection was performed with primary stapled anastomosis. A retrograde cholecystectomy was also performed at the same time.Her postoperative recovery was complicated by an anastomotic leak necessitating a relaparotomy and exteriorisation of the proximal colon. She made a slow but satisfactory recovery.Gross pathological examination  showed tColonic complications from pancreatitis are rare but are associated with substantial mortality and morbidity –5. TheseRecognition of large bowel involvement is difficult as symptoms may be nonspecific or masked by systemic features of pancreatitis . The devMany pathological hypotheses have been suggested for development of colonic obstruction following pancreatitis. External compression by the inflamed mesocolic mass can lead to necrosis of fatty tissue . Fat necPostoperative histology is useful to exclude primary large bowel pathology such as inflammatory bowel disease and neoplasia. In this case, histology confirmed the presence of scarring and pericolonic inflammatory changes secondary to pancreatic fat necrosis. Of note, though the initial gastrografin enema suggested the presence of a perforation, histology revealed an intact bowel wall. Gastrografin enema is very sensitive for the identification of radiological leak. However, as the patient responded to conservative management, it is unlikely that a significant clinical leak was present. Furthermore, as there was a lag period between the patient's gastrografin study and subsequent readmission and laparotomy, in the interim period a small perforation could have been sealed by fibrosis related to the inflammatory response. Consistent with this, the histology from the colonic resection revealed dense inflammatory infiltrates.Initial management of large bowel obstruction following pancreatitis should follow that of all cases of intestinal obstruction, with optimal fluid resuscitation and frequent review. CT has replaced contrast enema in the investigation of acute large bowel obstruction and has become a standard and acceptable baseline modality to both diagnose and characterise patients with symptoms suggestive of obstruction . With inNonoperative approach may include the placement of a colonic stent. The majority of the evidence for the use of colonic stenting is in the malignant setting . Its useIn those patients in whom conservative measures fail, surgery with resection of the stenosed section of bowel will be required. In this case, segmental colectomy followed by primary anastomosis was performed initially. Intraoperatively, it was felt that primary anastomosis was appropriate given the patient's good physiological status and age, as well as healthy and viable appearing bowel edges together with good vascularity and mobility. The available evidence suggests that segmental resection and primary anastomosis are an acceptable option in large bowel obstruction . This isIn patients in whom pancreatitis was caused by gallstones, cholecystectomy is suggested to reduce the risk of further pancreatitis . CholecyLarge bowel obstruction is a rare complication of acute pancreatitis but one that clinicians should be aware of due to its high mortality. Obstruction can occur after a significant delay following the resolution of pancreatitis. Those patients with evidence of colonic involvement on pancreatic imaging warrant further large bowel evaluation. Bowel resection may be required electively or acutely. Large multicentred data series are needed to determine optimum management. Colonic stenting has an increasing role in the management of large bowel obstruction but is a modality of treatment that needs further evaluation in this benign setting.


Adrenocortical carcinoma (ACC) is a rare and highly aggressive malignant neoplasm which can produce intravascular extension into the inferior vena cava (IVC) rarely extend into the right atrium (RA). We report a case of a male patient with large ACC with extension into the IVC and RA. Computed tomography showed a large right adrenal mass with contiguous tumor thrombus extending into IVC and RA with extension to the level of tricuspid valve. Patient underwent combined cardiac and abdominal surgical intervention on cardiopulmonary bypass with removal of the mass. Adrenocortical carcinoma (ACC) is a rare and highly aggressive malignant neoplasm with an incidence rate of 1 to 2 cases per million people per year.A 42-year-old male with medical history of hypertension and pre-diabetes presented with a 3-month history of fatigue and intermittent abdominal pain without exacerbating or relieving factors. Physical examination revealed right sided abdominal fullness but no palpable mass. Laboratory studies, including cortisol and urine metanephrine levels, were unremarkable. CT of the abdomen revealed a large right adrenal mass with contiguous tumor thrombus extending into IVC and right atrium RA with extension to the level of tricuspid valve (TV)  and 1B. Adrenocortical carcinoma is a rare and highly aggressive malignant neoplasm which can produce tumor thrombus extension into the IVC, rarely invade the RA and exceptionally extend across the tricuspid valve.7As initial study, CT imaging can distinguish benign from malignant adrenal tumors. The high lipid content in adenomas results in low attenuation in nonenhanced CT. Conversely, carcinomas, having less intracytoplasmic fat, will have higher attenuation and greater Hounsfield units than adenomas. Carcinomas also tend to have irregular shape and be of larger size (>4 cm). On delayed contrast-enhanced CT, adrenal carcinomas (as well as other nonadenomas) have delayed washout of contrast material.8MRI also has some added utility in identifying adrenal carcinomas. On conventional MRI, ACC shows equal intensity as liver on T1-weighted images and increased intensity on T2-weighted images. On gadolinium enhanced images malignant lesions show rapid and marked enhancement and a slower washout pattern. With MRI, involvement of the vena cava and cardiac structures is readily identifiable, hence its utility in surgical planning.9PET scanning with fluorodeoxyglucose (FDG-PET), especially when combined with CT, can be highly valuable in cases where an adrenal mass is very suspicious for malignancy. Adrenal carcinomas uptake FDG avidly, however pheochromocytomas and adrenal metastases do so as well. Alternative PET scan tracers, such as 11C-metomidate [MTO] might further improve specificity, by binding to specific enzymes only present in adrenocortical region.Precise radiological and echocardiographic evaluation of the extent of the tumor is essential to determine surgical approach. Complete surgical resection is the only curative option for localized disease. In cases of cavo-atrial extension complete resection using cardiopulmonary bypass is recommended.YD: Data acquisition, collection, manuscript writing and revision of final draft.FS: Data collection, manuscript writing and revision of final draft.HH and AW: Manuscript writing and revision of final draft.YD takes the responsibility and is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


The exact location of origin for giant cell tumors of bone (GCTB) remains controversial, as lesions are not routinely imaged early but rather late when the tumor is large and clinically symptomatic. At the time of diagnosis, GCTB are classically described as lucent, eccentric lesions with nonsclerotic margins, located within the epiphysis to a greater extent than the metaphysis. Here we present a case of a biopsy proven GCTB initially incidentally seen on MRI as a small strictly metaphyseal lesion, which over the course of several years expanded across a closed physis to involve the epiphysis and abut the articular surface/subchondral bone plate.  Giant cell tumors of bone (GCTB) are relatively common tumors, accounting for 5% of all primary bone tumors . GCTB moA 25-year-old man initially presented to an outside institution in 2011 with a history of a right knee hyperextension injury while playing basketball. He was evaluated with a right knee MRI that showed an anterior cruciate ligament (ACL) tear and a small subcortical lesion at the posterior aspect of the medial metaphysis of the distal femur that was nonspecific and too small to characterize; however, enthesopathy and small cortical based lesions such as nonossifying fibroma, enchondroma, fibrous cortical defect, and fibrous dysplasia were included in the differential diagnosis . He undeThe radiographs obtained in 2013 and 2015, two and four years, respectively, after the metaphyseal lesion was seen on the initial MRI, showed a well-marginated, locally aggressive, eccentric lesion in the right medial femoral condyle extending from the metaphysis to the epiphysis . MRI demDifferential diagnosis at this time was more limited and suggestive of GCTB based on age, location, and radiological criteria; however, aneurysmal bone cyst (ABC) and malignant tumors such as telangiectatic osteosarcoma or clear cell chondrosarcoma remained as alternative diagnoses. A total body bone scan was performed, demonstrating intense uptake in the right medial femoral condyle without other lesions identified . The pat USP6 gene rearrangement, characteristic of primary ABC [Macroscopic examination of the curettage specimen showed multiple, irregular fragments of rubbery, red-tan soft tissue, and white-tan hard osteocartilaginous tissue. Microscopic examination revealed blood-filled spaces lined by fibrous septa without an endothelial lining or vascular smooth muscle. The fibrous septa contained scattered multinucleated giant cells, abundant hemosiderin, osteoid matrix or reactive bone, and spindled mononuclear cells with plump nuclei without hyperchromasia or significant increase in mitoses, consistent with an aneurysmal bone cyst (ABC) component . In addimary ABC , was negThe patient has had an uncomplicated postoperative course: at 6 months after surgery, he has returned to pain-free, full activity, and postoperative radiographs showed no evidence of local recurrence.GCTB is characterized by the most recent World Health Organization classification as a benign but locally aggressive tumor . HistoloIn our patient, initial incidental MRI characterization was nonspecific and showed a small T1 hypointense and T2 heterogeneous subcortical intraosseous metaphyseal lesion. Follow-up radiographs 3 years later displayed the more typical radiographic features described above . USP6 gene, or secondary, arising in association with other benign or malignant tumors, including GCTB. Primary and secondary ABCs have a similar appearance radiographically and pathologically, and the diagnosis of GCTB with secondary ABC formation is typically confirmed with microscopic evaluation. Radiographically, ABC is more commonly characterized by a sclerotic margin, typically occurs in younger patients compared to GCTB, and often manifests fluid-fluid levels without other soft tissue components [Differential diagnosis included ABC which can be a primary, de novo neoplasm characterized by rearrangements of themponents . Rare prTreatment for GCTB is traditionally surgical with curettage and cement packing. However, the local recurrence rate has been reported to be as high as 25% depending on anatomical location , 11. PosWhile GCTB is classically described as abutting an articular surface, its location of origin remains somewhat controversial in the literature. GCTB most often presents in a skeletally mature patient with pain and at the time of initial imaging primarily involves the epiphysis . HoweverIn summary, to the best of our knowledge, this is the first case to clearly demonstrate multiple modalities of the unique progression of a pathologically confirmed GCTB in a single patient over four years from its origin in the metaphysis to its final eccentric location abutting an articular surface.


Inguinal hernias in women of reproductive age containing the ovary are very rare. When they occur in this age group, they are mostly associated with malformations of the urogenital system. Prompt surgical intervention is the key to ensure survival of the ovary. Here we present a case of an ectopic ovary presenting like an acute appendicitis.A 16-year-old Cameroonian girl presented at our emergency service with an acute exacerbation of a mild and intermittent right iliac fossa pain of 5 days’ duration. A clinical examination revealed android obesity and signs suggestive of an acute appendicitis. An abdominopelvic ultrasound scan showed an edematous right ovary in the canal of Nuck. A prompt hernia repair was done and her postoperative period was uneventful.An ectopic inguinal ovary remains a rare occurrence. An urgent and careful exploration of the hernia sac is the standard of care. Careful physical examination of obese girls and women is vital particularly in emergency settings, as obesity in our patient contributed greatly to a missed diagnosis. Clinicians should potentially consider the possibility of an ectopic ovary when faced with girls and women presenting with right iliac fossa pain. Inguinal hernias occur in less than 5 % of women. These hernias usually contain a variety of viscera, commonly the intestines and omentum. An inguinal hernia containing the ovary is very rare in women of reproductive age. Only 3 % of cases of inguinal hernias contain viscera such as female adnexa , 30 % of2 and waist circumference 101 cm. She had tenderness at the McBurney’s point, and positive Bloomberg, obturator, and psoas signs. The clinical presentation suggested a presumptive diagnosis of acute appendicitis.A 16-year-old Cameroonian girl presented to our emergency service with an acute exacerbation of a mild and intermittent right iliac fossa (RIF) pain of 5 days’ duration associated with anorexia and nausea. Her last menstrual period was 2 weeks prior to consultation. Her menarche was at the age of 12 years and she had a menstrual flow of 3 to 4 days with a regular cycle of 28 to 30 days. She was neither sexually active nor had a history of dysmenorrhea, and the rest of her past history was unremarkable. There was no vomiting, obstipation, fever, abnormal vaginal discharges, or urinary tract symptoms. On clinical examination, she was anxious with pain quoted 6/10 according to the visual analog pain scale, tachycardic (pulse rate of 110 beats per minute), and afebrile (maximum temperature of 36.8 °C). Her body mass index (BMI) was 34.2 kg/mA complete blood count (CBC) with differentials, C-reactive protein (CRP), and a urine analysis were normal, and her pregnancy test was negative. An abdominopelvic ultrasound scan revealed an edematous right ovary measuring 5.7×2.1×4.5 cm, in the canal of Nuck , gastrointestinal , and urologic . RIF pain due to ectopic ovary is relatively inconsistent with existing literature.The use of prosthetic materials for inguinal hernia repair yields the best results according to data from Europe and the USA . HoweverOnce the diagnosis of an ectopic inguinal ovary is made, prompt surgical intervention and hernia repair to salvage the ovary is recommended  to preveWe have presented a rare occurrence in the African literature of an ectopic inguinal ovary in a girl, initially misdiagnosed for an acute appendicitis. Special attention should be paid when examining obese girls and women presenting with a RIF pain especially in emergency settings, as obesity in our patient contributed in a missed diagnosis. Clinicians should endeavor to consider a broader perspective of differential diagnoses when faced with girls and women of reproductive age presenting with RIF pain. Appropriate imaging may, however, be particularly helpful in uncertain circumstances. Urgent and careful surgical exploration of the hernia sac remains paramount.


Spontaneous cerebrospinal fluid leaks are rare but may lead to confusion with other diseases in patients without history of trauma. We report a rare case unusual for two reasons. First, our patient was put under antiallergic medication for months before the diagnosis of spontaneous cerebrospinal fluid leak of the sphenoid sinus. Second, our patient was managed successfully by a ventriculoperitoneal shunt.Our patient was a nonobese 49-year-old Arab man without history of trauma or surgery who presented with rhinorrhea. He was given allergic rhinitis medication for 4 months without improvement. After the onset of headache leading to the suspicion of paranasal sinusitis, a computed tomography scan discovered an osteodural defect in the sphenoid sinus roof and a magnetic resonance imaging scan showed an aspect of empty sella with an arachnoidocele. An eye fundus examination found papilledema suggesting the diagnosis of idiopathic intracranial hypertension. We performed a ventriculoperitoneal shunt without repair of the osteodural defect. Because of the favorable evolution, we decided to postpone surgery.Spontaneous cerebrospinal fluid leak should be considered even in nonobese male patients without history of trauma. Our observation adds to other case reports suggesting the decrease of cerebrospinal fluid pressure alone as an option for the treatment of spontaneous cerebrospinal fluid leaks. Additional studies are necessary to clarify the indications. Cerebrospinal fluid (CSF) leaks are rare, but their complications, such as meningitis or brain abscess, are life-threatening . They reWe describe the case of a patient who presented with CSFR due to idiopathic intracranial hypertension (IIH) with a breach in the sphenoid sinus roof and an aspect of empty sella and arachnoidocele on magnetic resonance imaging (MRI). In the light of this observation and a review of the literature, we will discuss the different aspects of this rare entity.We report the case of a 49-year-old Arab man with no history of head injury, obesity or high blood pressure. The onset of his symptoms was about 4 months earlier with a flu-like syndrome followed by a persistent clear bilateral rhinorrhea. The diagnosis of allergic rhinitis was suspected and our patient was given antihistamine and nasal corticosteroids without improvement. He presented to our outpatient clinic with a slight headache without fever. His overall health was maintained and a neurological examination was normal. A computed tomography (CT) scan showed a hypertrophy of the inferior nasal turbinates and a soft tissue density filling in the right sphenoid sinus with thinning and attenuation of its roof and a posterior bony defect at this level Fig. . An MRI An eye fundus examination discovered signs of intracranial hypertension with early papilledema without functional impairment. Hormonal determination found normal thyroid-stimulating hormone (TSH), free T3 and T4, cortisol, adrenocorticotropic hormone (ACTH), lactate dehydrogenase (LDH), follicle-stimulating hormone (FSH) and luteinizing hormone (LH) with a slight prolactin elevation to 369.5 μUI/mL .Our patient was given acetazolamide, ranitidine, paracetamol and amoxicillin with clavulanate. A ventriculoperitoneal shunting was performed resulting in an improvement of the rhinorrhea. The evolution was favorable with disappearance of the rhinorrhea in the last follow-up carried out 1 year after the procedure. The postoperative ophthalmological evaluation including a fundus examination was normal. Due to the favorable evolution, we decided to postpone surgery.The term “spontaneous” CSFR has been applied to the cases unrelated to trauma, surgery, malformation, tumor, or previous radiation therapy , 7, 8. TPatients presenting CSFR without history of surgery or trauma are classically obese, hypertensive, multiparous women in their fourth or fifth decades, with women outnumbering men 2:1 . The cliThe classical site of the breach is located in the anterior cranial fossa , 13. HowThe localization of the breach is a neuroimaging challenge. It allows for the planning of the surgical approach, and requires a CT scan that should ideally be spiral with multiplanar reconstruction. The objective is to visualize the sinus fillings and the bone defect. However, MRI is a better choice because of its multiplanar acquisitions and nonradiating character . AdvanceThe MRI aspect of empty sella is highly associated with spontaneous CSF leaks and IIH . A studyThe content of osteodural defects is variable: meningocele, meningoencephalocele, encephalocele, meningeal or arachnoid hernia, arachnoid diverticulum, or arachnoid cyst. This content may modify the preoperative planning and the grafting technique .Acetazolamide, which was used in our case, is a diuretic of the carbonic anhydrase inhibitor type. It can decrease CSF production up to 48 % .CSF diversion can be performed by lumboperitoneal or ventriculoperitoneal shunts, and occasionally by ventriculojugular and ventriculoatrial shunting. Complications of CSF diversion include shunt blockage, infection, abdominal and back pain, intracranial hypotension, and tonsillar herniation. No prospective controlled trials have been made to guide the choice of procedure . AlthougA subcranial approach may offer a broad exposure of the fronto-sphenoid-ethmoidal anterior midline and the posterior planes of the anterior fossa skull base, providing a safe and effective technique for repair of CSFR with the advantages of avoiding frontal lobe retraction . HoweverOf all the CSF leaks, those from the sphenoid sinus represent a unique challenge due to the anatomical rapport and the extreme variability in the shape of the sinus . In our There is overwhelming evidence in the literature that the underlying cause of the vast majority of spontaneous CSF leaks is elevated ICP, and that the entity represents a variant of IIH , 10, 11.


Caecal perforation is a life-threatening complication of large bowel obstruction with a reported mortality of 34% to 72%. This case describes the novel use of percutaneous needle caecostomy as a life-saving measure to prevent imminent caecal perforation in a 68-year-old lady with large bowel obstruction secondary to an incarcerated incisional hernia. After careful review of computed tomography images and measurement of distances from the abdominal wall to the caecum, the patient's caecum was decompressed in the emergency department using a needle under local anaesthetic. The patient subsequently underwent laparoscopic hernia repair and had an uncomplicated recovery. When conducted safely and with precision in an appropriate patient, percutaneous needle caecostomy can provide immediate symptom relief, reduce risk of caecal perforation, and allow a laparoscopic surgical approach. Caecal perforation is a life-threatening complication of large bowel obstruction with a competent ileocaecal valve. It has reported mortality ranging from 34% to 72% in case series . This caA 68-year-old lady was brought in by ambulance with a one-day history of bilious vomiting, severe colicky abdominal pain, and profuse watery diarrhoea. She had a background of primary lung adenocarcinoma, for which she had completed neoadjuvant chemotherapy 5 months ago. Surgery was abandoned after repeat staging PET/CT scan revealed sacral metastases. Her other medical comorbidities included thalassaemia, osteoporosis, and previous transient ischaemic attack. Her surgical history included an abdominal hysterectomy which was complicated by rectal injury requiring a Hartmann's procedure that was subsequently reversed. Her regular medications were erlotinib 150 mg daily, Asasantin SR, and alendronate. On examination, she had a low grade tachycardia of 90 bpm and blood pressure of 110/70 mmHg. Her abdomen was grossly distended and peritonitic with a palpable hernia containing bowel in the left lower quadrant. Urgent abdominal CT (computed tomography) was performed, which indicated a severe large bowel obstruction secondary to herniation of transverse colon into an incisional hernia at the previous colostomy reversal site . The proIndications for caecostomy include palliation of malignant bowel obstruction, decompression in chronic intestinal pseudo-obstruction, and administration of anterograde continence enemas in patients with defecation disorders, particularly in patients with spinal cord injury or severe disability –4. TradiThere are limitations to the technique of needle caecostomy. It is highly operator dependent and should only be performed after careful review of CT images by a surgical trainee or a surgeon with appropriate experience, followed by radiological or surgical confirmation of technique success. Percutaneous needle caecostomy would also prove difficult in patients with significant body habitus or extensive previous intra-abdominal surgery (due to likely adhesions).This case shows that needle caecostomy can be effectively and safely performed to produce emergent caecal decompression. However this technique is not advocated for all patients and is not a definitive intervention. It is intended as a life-saving measure in patients with impending caecal perforation.


A 70 year-old man, farmer by profession consulted for a firm and painless nodule of the back of his right hand that was evolving since 09 years. The clinical examination revealed a subcutaneous nodular lesion; firm; immobile and painless. The diameter was about 0.8cm. The skin above was normal. Surgical excision was indicated. Intraoperatively the lesion was cystic and surrounded by a whitish membrane. Histological examination confirmed an epidermoid cyst who was abducted in totality. The occurrence of epidermoid cyst in hands can be explained by repeated trauma. It is seen most often in men “a manual worker.” Clinically, it is about a firm nodule often sitting at the distal phalanx in size from 0.5 to 2cm. The Pulp location is the common location against in back of the hand which is possible but unusual, as in our patient. The overlying skin is normal or punctuated and the lesion is painless in half of the cases. Treatment is the complete surgical excision of the capsule and the overlying skin to avoid the risk of recurrence.


The high number of knee imaging exams at radiology clinics, together with thewide variety of knee disorders, calls for expanding the knowledge about the lesscommon lesions seen in routine diagnostic practice. The purpose of thispictorial essay was to illustrate unusual lesions that distend the knee joint,selected by relevance and evaluated with multiple imaging modalities, includingX-ray, computed tomography, and magnetic resonance imaging, as well as toperform a brief review of the literature. The knee is the site of a variety of changes,particularly degenerative and traumatic changes such as fractures and meniscaltears, as well as osteochondral and ligament lesions, which are usual in routinediagnostic practice. However, the high demand for imaging exams to evaluation thisarticulation calls for knowledge of less common knee lesions, such as pseudotumorsand tumors , such as intracapsular chondroma and lipomaarborescens. All of these diseases have their own radiological approach, which isessential for the diagnostic rationale, which prompts a discussion of theiraspects.A number of recent studies conducted in Brazil have highlighted the importance ofimaging methods in the evaluation of diseases affecting the musculoskeletalsystem. It can beprimary or secondary to mechanical or inflammatory stress. Although it is a benign neoplastic process, itcan be aggressive, even evolving to extracapsular involvement,11. Malignant degeneration to chondrosarcoma occurs in 5% ofcases of primary synovial chondromatosis.First described in 1813, synovial chondromatosis results from chondroid metaplasia ofsynovial joint tissue and can occur along tendon sheaths as well as synovialbursae,11. The imagingfindings on computed tomography (CT) and magnetic resonance imaging (MRI) are oftenpathognomonic, including lobular synovitis and multiple intra-articular loosebodies, with a pattern of chondroid calcification, initially adhered to thesynovium withsubsequent detachment. There can also be erosion of the articular bonesurfaces. In MRI,loose bodies show hypointense signals on T1-weighted sequences and hyperintensesignals on T2-weighted sequences, due to the high amount of water in cartilagetissue, with foci of signal reduction, corresponding to calcifications  form has been described, the secondary form is more common and canoccur in various types of inflammatory synovitis, such as rheumatoid arthritis.There is a significant association between lipoma arborescens and osteoarthritis,especially in the elderly, because chronic irritation is the mechanism that triggersthe synovial response. Although there have been reports of involvement in variousjoints, the knee is the most common site,16.Initially described by Hoffa. Treatment is by arthroscopic synovectomy, and recurrenceis uncommon.MRI can facilitate the diagnosis, demonstrating a frondlike synovial mass that isisointense in relation to fat, an aspect considered pathognomonic  and 5. L. From a clinical perspective, thesymptoms are local pain and swelling, as well as impaired mobility,18, affecting a single knee in 80% of cases. The term pigmented is appliedbecause of recurrent hematogenous effusion, as evidenced by hemoglobin degradationproducts.Pigmented villonodular synovitis is characterized by benign synovial proliferation,which can arise not only from the joint synovium but also from synovial bursae andtendon sheaths, and can be classified as intra- or extra-articular,19. Joint swelling and edema of periarticular softtissue are common. Bone rarefaction, joint degenerative changes, and intra-articularloose bodies are less common, being more common in the diffuse form of thedisease. MRI providesbetter tissue differentiation, allowing identification of membranous synovialproliferation and joint effusion (.Findings in the various methods depend on the subtype of pigmented villonodularsynovitis, which has extra-articular, intra-articular, diffuse, and localized forms.It manifests as a mass with soft tissue density, usually with no signs of subjacentbone involvement. In approximately 20% of cases, usually in congruent joints such asthe ankle and elbow, bone erosion may occur, which tends to be extrinsic and havesclerotic borders, possibly deriving from the activity of proteolyticenzymeseffusion .The def,21, preferably affects individuals between 20 and 40years of age, and most often affects the knee. In many cases, it originates from adjacent tendon sheathsand bursae, although it can occur at sites without synovial tissue. Only 5.0-10.0%of cases have an intra-articular component, and synovial sarcoma primarily originating from bone isextremely infrequent.Synovial sarcoma represents approximately 2.5-10.0% of malignant soft tissuetumors,22.The diagnostic imaging of synovial sarcoma represent a challenge due to the absenceof a specific pattern. In 50% of cases, an X-ray will show no changes, althoughcalcified foci, generally eccentric and peripheral, are seen on X-rays inapproximately 30%. Involvement of subjacent bone is uncommon, and, when it occurs,erosion has an indolent pattern, with signs of aggressive invasion in only 5% ofcases. The appearance on CT is of a heterogeneous lobular mass with areas ofcystic/necrotic degeneration and post-contrast nodular enhancement,22. The lesion usually has multiloculated aspect anda heterogeneous signal on T1-weighted sequences, a triple-intensity signal,characterized by interposed areas of hyperintensity, isointensity, andhypointensity, on T2-weighted sequences having been described. Areas of hemorrhageand cystic degeneration are common and can have a "bowl of grapes" aspect, as wellas forming liquid-liquid levels (MRI is the method of choice for evaluating synovial sarcoma, because it providesinformation on the extent of the tumor and involvement of the neurovascularbundled levels ..Patellar neoplasms are rare conditions, the most common being chondroblastoma. Ananeurysmal bone cyst of the patella is an even less common type of benign neoplasm,which was first described by Jaffe and Lichtenstein in 1942. It commonly occurs inyoung women and can be primary or secondary to trauma, chondroblastomas, giant celltumors, or even osteosarcomasOn CT, an aneurysmal bone cyst of the patella appears as an expansile, multiloculatedlytic lesion. On MRI, the lesion can show hyperintense content on T2-weightedsequences and fluid-fluid levels can typically be seen .,25. It predominantly affects men and is solitary in 90% ofcases. When multipleosteochondromas occur, they are associated with hereditary multiple exostoses, anautosomal dominant disorder.Osteochondroma is the most common benign bone tumor and accounts for approximately20-25% of benign bone lesions. It originates from the growth plate and consists ofmedullary and cortical bone, surrounded by a hyaline cartilage cover,25. It isnoteworthy that thrombosis or rupture can complicate a pseudoaneurysm, which makesearly diagnosis and treatment important. The differential diagnosis includes theformation of a synovial pseudobursa, as a secondary reaction to osteochondroma,which is distinct from a pseudoaneurysm in that it lacks a relationship with thepopliteal artery, shows standard peripheral contrast enhancement as well as nodetectable Doppler flow. Factors that can pose challenges in the differentialdiagnosis include complications of the two diseases, such as bleeding inpseudobursae and thrombosis in pseudoaneurysms.The fixed position of the popliteal artery in the adductor canal, together with thehigh prevalence of osteochondroma at this site, favors the development ofpseudoaneurysm of the popliteal artery, which, albeit a rare condition, is the mostcommon vascular complication of osteochondromaArteriography and Doppler ultrasound are the main methods for the diagnosis ofpseudoaneurysm, and conventional X-ray can be used in the diagnosis ofosteochondroma. Contrast-enhanced CT and MRI can also aid in the diagnosis andsurgical planning .The variety of lesions that affect the knee is extensive, as is the demand forimaging exams to evaluate this articulation in the diagnostic imaging services,factors which call for expanding the knowledge of unusual disorders in the everydaypractice of radiologists.


An otherwise healthy 36-year-old man presented with sudden-onset right upper quadrant abdominal pain and vomiting. A bedside ultrasound, performed to evaluate hepatobiliary pathology, revealed a normal gallbladder but free intraperitoneal fluid. After an expedited CT and emergent explorative laparotomy, the patient was diagnosed with a small bowel obstruction with ischemia secondary to midgut volvulus. Though midgut volvulus is rare in adults, delays in definitive diagnosis and management can result in bowel necrosis. Importantly, an emergency physician must be able to recognize bedside ultrasound findings associated with acutely dangerous intrabdominal pathology. Fifty percent of midgut volvulus cases present within the first month of life, and 90% in the first year.2 saturation 100%. His examination revealed a firm abdomen, significant right upper quadrant tenderness, and voluntary guarding. Soon after the initial exam, the patient had a second episode of non-bloody, non-bilious vomiting for which he was given ondansetron, ranitidine, and one liter of 0.9% normal saline. A prompt point-of-care ultrasound (POCUS) demonstrated a normal gallbladder. However, it also showed free intraperitoneal fluid in Morison’s pouch and a loop of distended bowel with wall edema , his pain was rated 9/10 and his vital signs were temperature 97 F (36.1 C), pulse 61, respirations 18, blood pressure 155/103, and Oll edema . An upriPresuming an acute abdomen, we contacted surgery for emergent consultation and transported the patient for an expedited computed tomography (CT) abdomen and pelvis with intravenous contrast. The venous lactate level returned at 6.1 mmol/L which prompted the administration of a bolus of two additional liters of normal saline using pressure bags.The attending radiologist interpreted the CT:“Malrotation with the third portion the duodenum...Multiple dilated loops of jejunum with suggestion of wall thickening…Distorted mesenteric anatomy with a swirled appearance of the mesenteric vessels. Given this constellation of findings, the appearance is suspicious for a volvulus with early or partial bowel obstruction.”The patient was taken emergently to the operating room where midgut volvulus was confirmed. According to the perioperative documentation, the entire small bowel was black, and upon manual detorsion, portions of the bowel regained its normal, pink color indicating restored perfusion. The assisting pediatric surgeon successfully performed a Ladd Procedure, and the abdomen was left open.On the second hospital day, another evaluation in the operating room revealed bowel with both venous congestion and edema but without necrosis. The bowel appeared both viable and peristaltic. On the fourth hospital day, a third and final inspection demonstrated pink and healthy bowel with decreased edema. After decompressing the gastrointestinal tract, the abdomen was closed. The patient was discharged on his ninth hospital day without any additional complications and has continued to do well during follow-up visits.Malrotation is defined as an abnormal twisting of the small intestines during embryological development, whereas volvulus refers to the condition when this abnormal twisting results in bowel and vascular obstruction.9CT findings for midgut volvulus fall into three categories: Mesenteric ischemia, small bowel obstruction, and anatomic abnormalities. A finding specific to midgut malrotation is the “whirlpool sign,” which refers to the swirled appearance of the mesentery and superior mesenteric vein (SMV) when they are wrapped around the superior mesenteric artery (SMA) (Image 2).16Emergency physicians are focused on differentiating between sick and not sick. In this patient, the POCUS findings of intraperitoneal free fluid and bowel wall edema significantly expedited specialty consultation and confirmatory diagnostic testing. Without POCUS, manual detorsion in the OR would have been delayed, and the marginally viable bowel may not have been saved. The use of early ultrasonography is well supported by the literature. In two recent studies, POCUS helped the provider in 83–87% of patients with undifferentiated acute abdominal pain.24In this case, the finding of intraperitoneal free fluid on POCUS raised the provider’s level of suspicion for acutely dangerous pathology. In a retrospective review of pediatric patients with acute abdominal pain, free fluid on diagnostic imaging doubled the rate of a surgical condition from 25% to 57.4% (p<0.001) as well as increased the rate of surgery from 6.3% to 94.4% (p<0.001).A patient with right upper quadrant pain and vomiting may reasonably be suspected to have gallbladder disease. POCUS in this case did not reveal gallbladder pathology but did serve to identify an extremely sick patient with an alternative diagnosis and resulted in an acceleration and prioritization of this patient’s care. Delays in care could have been catastrophic for this patient. While midgut volvulus case reports and series have been published in the surgical literature, this diagnosis has had limited representation in the emergency medicine literature. Emergency physicians should be aware of this diagnosis as well as the sonographic findings in the abdomen that are predictive of pathology that may require surgical intervention. Care of these patients must be expedited, as a delay to definitive diagnosis and treatment may lead to increased morbidity and mortality. In patients with midgut volvulus with associated small bowel obstruction and ischemia, “time is bowel.” An awareness of this potentially life-threatening diagnosis can reduce time to confirmatory testing and definitive treatment in the operating room.


Spontaneous spinal epidural hematoma (SSEH) is a rare diagnosis. One known risk factor is anti-coagulation medication. We present a case of SSEH in a 74-year-old male on rivaroxaban therapy who clinically presented with an intermittently resolving and then worsening neurological exam. Due to the extremely high morbidity and mortality associated with this diagnosis, it is important to be aware of the various presentations and adverse effects related to novel anticoagulation. Spinal epidural hematomas are a rare event. The estimated incidence is 0.1 per 100,000 per year with a frequency accounting for less than 1% of spinal epidural space-occupying lesions.4Even more rarely, spinal epidural hematomas can occur spontaneously. Cases have been reported with coughing, stretching, and even playing the trombone.10There is no clear consensus on whether the pathophysiology of the hemorrhage is arterial or venous.17Spinal epidural hematomas typically present clinically as a cord compression syndrome. The most common presenting complaint is the acute onset of neck or back pain with associated neurological deficit such as weakness of the extremities.19A 74-year-old man on rivaroxaban for paroxysmal atrial fibrillation presented with the gradual onset of neck pain. The pain started while he was walking in the woods and was associated with progressive weakness and numbness from the clavicles downward. He was able to walk back to his cabin, but upon arrival he was unable to maintain his balance and fell forward striking his head. He denied any loss of consciousness. He was unable to move for about 45 minutes. Emergency medical services was called and they noted the patient to be completely paralyzed with fecal incontinence. He also had shortness of breath. During his transport to the emergency department (ED) he started to regain strength and feeling in his arms and legs and improvement of his shortness of breath. He denied any recent fevers, upper respiratory infection, rash or tick bites. All other review of systems was negative. Past medical history was significant for hypertension, atrial fibrillation, and coronary artery disease.On initial examination, the patient was alert and oriented to person, place, and time. Temperature was 92.0 degrees Fahrenheit tympanic, pulse 56 beats per minute, respiratory rate 20 breaths per minute, blood pressure 122/56 mmHg, oxygen saturation 100% on four liters nasal cannula. Lungs were clear to auscultation bilaterally without wheezes, rhonchi, or rales. Heart was regular rate and rhythm, without any murmurs. Abdomen was soft, non-tender, non-distended with normal bowel sounds. Back had no evidence of trauma or deformity, non-tender to palpation. On extremity exam he had 4/5 strength in all extremities. After 20 minutes in the ED, he developed flaccid paralysis of all extremities with 0/5 strength. His voice also became softer and he developed shortness of breath. After five minutes he was able to wiggle his left toes. Over the next hour he slowly regained strength in his right lower extremity and his voice returned to normal. After another 40 minutes the patient was able to move his right upper and lower extremity and wiggle his toes on his left lower extremity. He was still unable to move his left upper extremity.A computed tomography angiography (CTA) of the chest, abdomen, and pelvis was performed and did not show any evidence of aortic dissection. MRI of the cervical spine showed a prominent epidural hematoma, primarily dorsal, that extended from the foramen magnum down to cervical vertebra C7 and contributed to severe mass effect on the thecal sac . FindingThere have only been four other cases of SSEH formation while on rivaroxaban25What do we already know about this clinical entity?Spontaneous spinal epidural hematoma (SSEH) is a rare diagnosis. There are several risk factors, including anticoagulation medications. Typically the disease presents as a cord compression syndrome.What makes this presentation of disease reportable?This case was interesting in that the neurological symptoms were waxing and waning. There have also been few cases reported of SSEH on rivaroxaban.What is the major learning point?While SSEH will usually present as a cord compression syndrome, it is important to consider this diagnosis in patients on rivaroxaban or other novel anticoagulation medications with an atypical presentation.How might this improve emergency medicine practice?Due to the extremely high morbidity and mortality associated with this diagnosis, it is important to be aware of the various presentations and adverse effects related to novel anticoagulation.This case was interesting in that the neurological exam was waxing and waning, rather than a clear neurological deficit as one would expect from a compression syndrome. In other cases of SSEH caused by novel anticoagulants, two resolved spontaneously without the need for surgery, whereas the third and fourth required surgical intervention.17As the use of new anti-coagulant medications such as rivaroxaban increases, there will likely be an increase in adverse events and new complications. SSEH may be one of them. The varied presentations and lack of clear inciting factor make SSEHs difficult to diagnose in the ED. While this is a rare diagnosis, anticoagulation medication is a known risk factor. Given the increased morbidity and mortality associated with this diagnosis and the use of new anticoagulation medications, it is important to be aware of these unusual presentations of SSEHS.Spontaneous spinal epidural hematomas are a rare but serious diagnosis. Knowing the risk factors associated with this serious illness is important to recognize in emergency medicine. As new anticoagulant medications such as rivaroxaban are becoming more widely used, adverse effects from these medications will likely become more prevalent, and SSEH is likely one of them.Documented patient informed consent and/or Institutional Review Board approval has been obtained and filed for publication of this case report.


Metanephric adenofibroma is a rare, biphasic, benign tumor containing both stromal and epithelial components and could be potentially mistaken as Wilms’ tumor (WT). We present a 5-year-old girl who was suspected to have metastatic Wilms’ tumor on radiological investigations/tru-cut biopsy and had received neoadjuvant chemotherapy, but postoperatively final histopathology revealed it as metanephric adenofibroma. No postoperative chemotherapy was given Wilms’ tumor is the most common tumor of kidney in the pediatric age group and is easily diagnosed on biopsy, but with recent recognition of various other pediatric renal mass of different biologic behavior the role of pathologist for correct diagnosis is more important. Metanephric adenofibroma (MAF) is one of the rare benign tumors of kidney that could be easily mistaken for Wilms’ tumor (WT). [1]A 5-year-old girl presented with progressively increasing abdominal lump for seven months. Lump was not associated with pain, fever, hematuria or vomiting. Examination revealed a large right renal mass involving the right lumbar, right hypochondrium, right iliac fossa and extending into the umbilical and hypogastric regions of the abdomen. Contrast enhanced computed tomography (CECT) abdomen and thorax showed 16cm x13cm x13cm minimally enhancing solid mass lesion involving entire right kidney  and subcentimetric peripheral nodules in left lung. There was no evidence of extension into the adjacent adrenal gland, renal vein, or inferior vena cava. Tru-cut biopsy gave differential diagnoses of mesenchymal variant of Wilms’ tumour and cellular mesoblastic nephroma. Based on findings of clinical, radiological and histopathological examination, provisional diagnosis of metastatic WT was kept. The patient received 6 cycles of AVD regime based chemotherapy considering it to be Stage IV Wilms’ as per SIOP protocol. Post chemotherapy CECT showed complete resolution of lung nodules with no significant change in size of renal mass. Patient underwent right simple nephroureterectomy with lymph node sampling. However, final histopathology report showed tumor composed of bland spindle cells without mitosis and pleomorphism with scattered adenomatous foci composed of small tubules lined by nondescript cuboidal epithelium. These features were suggestive of metanephric adenofibroma with clear margins . In view of the benign nature of the lesion, we decided on no further toxic chemotherapy and monthly follow up with clinical and ultrasound examination to look for any recurrences.Child is doing well on follow up with no evidence of recurrence in last five months.Hennigar and Beckwith were the first to describe MAF in 1992.[1] It is a rare, biphasic, benign tumor containing both stromal and epithelial components in various proportions. This tumor is classified among the metanephric neoplasms, which also include metanephric adenoma and metanephric stromal tumour. Metanephric adenoma (MA) is a purely epithelial lesion and metanephric stromal tumor (MST) is a purely stromal lesion, while MAF is in between them. MAF lies in a spectrum between the MA and MST and could also merge with the morphology of WT thus it supports the concept that these all are related lesions.[2-4]. In our case too, the tru-cut biopsy was not conclusive of WT as the pathologist suggested a possibility of mesenchymal variant WT and cellular mesoblastic nephroma. Differentiating MAF with cellular mesoblastic nephroma may at times be also difficult, though certain features may be useful in distinguishing this stroma from congenital mesoblastic nephroma (CMN) that includes intratumoral angiodysplasia, concentric cuffing of entrapped tubules ("onion skinning"), and heterologous differentiation.[2] At present no particular immunohistochemistry findings are diagnostic of metanephric adenofibroma. The epithelial component is positive for AE1/3 and WT1, while the stromal component is positive for Vimentin and CD34.[2]Clinically, the child may present with polycythemia, hypertension, or hematuria, which resolve following nephrectomy.[1] These tumors can achieve significant size and present with a palpable mass in abdomen and it is not possible to distinguish these tumors from other paediatric solid tumors radiologically. As it is a rarity, there is no standard treatment protocol but being a benign tumor simple nephrectomy is curative, though there have been reports of even partial robotic nephrectomy.[5] Majority of patients have good prognosis and don’t have recurrence on follow up.[6] There is no role for chemotherapy or radiotherapy in management of MAF. In our case, neoadjuvant chemotherapy was administered as the tru-cut biopsy diagnosis was WT, though there was no significant reduction in the size of tumor following chemotherapy, but the subcentimetric lung nodules resolved.Though we cannot conclusively rule out the possibility of malignant metanephric adenosarcoma in view of the subcentimetric lung nodules, but as the histopathology came out be benign we decided to follow up the patient rather than to subject her to further chemotherapy and radiotherapy. Moreover, metanephric adenosarcoma is extremely rare. Nevertheless, its possibility has to be kept in mind and a regular follow up is warranted.To summarize, metanephric adenofibroma, though rare, should be kept as a differential for a large renal masses presenting outside the spectrum of routine Wilms’ tumor presentation. This can avoid toxic chemotherapy and its complications.Source of Support: NilConflict of Interest: None declared


Intestinal intussusception is the most frequent cause of small bowel obstruction in children between the ages of 2 months and 5 years and often remains idiopathic in etiology, even after surgery. On microscopic examination, in intussusception normal mucosa is noted but in a few cases heterotopic tissue can be seen. Heterotopic gastric mucosa in the small intestine is extremely rare except for its occurrence in remnants of Meckel’s diverticulum. In view of the rarity of this condition, we report a case of ectopic gastric mucosa in the small intestine that was not associated with remnants of vitelline duct.A 6-year-old boy of Indo-Aryan ethnicity from India presented with episodes of acute abdominal pain and distension with vomiting and non-passage of stools. On ultrasonography intussusception was suspected. A laparotomy was done and the ileal segment (tip of intussusception) was sent for histopathological examination. On histopathology, sections from the tip of intussusception showed extensive gastric metaplasia of the mucosa.A definitive diagnosis of heterotopic gastric mucosa is established by histopathological examination and it is important to differentiate heterotopia, which is a developmental anomaly, from metaplasia, which is an acquired condition. Heterotopic gastric mucosa is usually clinically silent and surgical intervention can be considered in patients with complications such as gastrointestinal hemorrhage and intestinal obstruction. Intestinal intussusception is the most frequent cause of small bowel obstruction in children between the ages of 2 months and 5 years; it often remains idiopathic in etiology, even after surgery. According to a study, approximately 75% of children with intussusception caused by intestinal obstruction were in their first year of life, which is in concordance with other studies where the commonest age group affected was below 1 year .On microscopic examination, in intussusception normal mucosa is noted but in a few cases heterotopic tissue can be seen. In view of the rarity of this condition, we report a case of a 6-year-old boy with heterotopic gastric mucosa (HGM) in the small bowel.A 6-year-old boy of Indo-Aryan ethnicity from the northern part of India presented with episodes of acute abdominal pain and abdominal distension with vomiting and non-passage of stools. He denied a history of taking any medications in the past and his family history was not contributory. A physical examination was normal except for slight pallor. There was no hepatosplenomegaly. His complete blood counts, erythrocyte sedimentation rate (ESR), and serum electrolytes were within normal limits. On ultrasonography intussusception was suspected along with enlarged multiple mesenteric lymph nodes. At laparotomy, small bowel intussusception was found which was irreducible so a resection anastomosis was performed and the ileal segment (tip of intussusception) was sent for histopathological examination.We received a part of the ileal segment measuring 3 × 1.5 cm; the external and cut surfaces were unremarkable Fig.  and 3. FAberrant gastric gland is the term used where gastric glands are found in an organ other than the stomach. HGM of the intestinal tract is an occasional incidental gross or microscopic finding at surgery or autopsy . HGM wasIt is classified as either acquired metaplasia as in Barrett’s esophagus or a true gastric heterotopia of congenital origin as in Meckel’s diverticulum. The biggest diagnostic dilemma is of a simple true congenital gastric heterotopia being misdiagnosed as a gastric metaplasia .HGM may be found anywhere in the gastrointestinal tract from the tongue to the rectum . It is cClinical presentation varies and depends on the size and location of HGM. It usually presents as an inlet patch in the proximal esophagus, as polypoid masses in the rectum, or as nodular tumors in the duodenum , 12. MosDepending on the location, three mechanisms have been suggested for the development of HGM. One possibility is that during the developmental descent of the stomach, remnant tissue could have remained in the distal esophageal portion of the gut. However, although this mechanism could explain gastric heterotopia of the esophagus, it cannot explain gastric heterotopia in more distal intestinal tracts .It has also been said that the condition may be acquired and is the result of an abnormal regenerative process following destruction of the normal intestinal mucosa. Acquired HGM is common in the jejunum and ileum in areas of mucosal regeneration accompanying inflammatory lesions such as regional enteritis . HoweverThe third and most possible hypothesis is that HGM is the result of abnormal differentiation of local tissue. Pluripotent primitive endoderm stem cells have the ability to differentiate into cell types of the gastrointestinal epithelium. An error in differentiation could lead to the gastric mucosa being present anywhere throughout the gastrointestinal tract , 19.It is important to differentiate heterotopias from metaplasias. Metaplasia is a change of one type of full developed tissue to another differentiated tissue usually due to sustained inflammation and its complications. Heterotopias imply a developmental anomaly, whereas metaplasias imply an acquired condition. The common sites of gastric metaplasia occurring as a protective response to the injurious action of gastric acid are the lower esophagus and duodenal bulb.In a case of acquired HGM, gastric mucosa consists mainly of mucus-secreting cells with the appearance of gastric pyloric glands. Parietal and chief cells are absent or, if present, are sparse. However, HGM consists of full mucosal thickness of structured gastric fundic mucosa consisting mainly of chief and parietal cells; the abnormality is considered developmental or congenital in origin as was seen in our case . Thus, wDefinitive diagnosis of HGM is established by histopathological examination and it is important to differentiate heterotopia, which is a developmental anomaly, from metaplasia, which is an acquired condition. It is usually clinically silent and does not require treatment. However, surgical intervention can be considered in patients with complications such as gastrointestinal hemorrhage and intestinal obstruction .


Acute gastrointestinal obstruction can have a varied spectrum of clinical presentation and etiologies. It has been studied in detail and the management criteria have been well defined for the most part in our era. The etiologies are usually well defined. However, acute small bowel obstruction (SBO) due to intussusception caused by an inverted Meckel's diverticulum is a rare phenomenon that is often times missed on initial presentation and/or consequently until resected and visualized on pathological examination. We present a case of a 34-year-old presenting with symptoms and signs of acute intestinal obstruction and radiographic exam showing ileo-ileal intussusception. The patient failed to improve initially following conservative management and was taken to the operating room for small bowel resection which then revealed an inverted Meckel’s diverticulum. Small bowel obstruction is more common than colon obstruction, and its incidence is about 350,000 per year in the US. It comprises about 15% of all acute surgical gastrointestinal admissions and about the same proportion of emergency admissions for abdominal pain [A 34-year-old male with a past medical history of gastroesophageal reflux disorder presented to the emergency room with diffuse crampy abdominal pain since four months progressively worsening over two to three days, which was associated with nausea, bilious vomiting, and obstipation. Physical examination was notable for abdominal distention and tenderness in the right lower quadrant with no significant guarding or rigidity. A nasogastric tube was placed for decompression and the patient was resuscitated with intravenous fluids with moderate improvement of symptoms. Laboratory tests were unremarkable. Computed tomography (CT) of the abdomen and pelvis was performed, which showed right lower quadrant ileo-ileal intussusception with hypodensity distal to the collapsed distal ileum Figures -2.The patient was scheduled for emergent operative intervention. Exploratory laparotomy was performed and bowel was inspected. Small bowel loops were found dilated till the distal ileum where an intussusception was identified approximately 40 cm proximal to the ileocecal valve with a discrete palpable mass within the ileum. En bloc resection of the small bowel with adequate margin was performed and side-to-side  anastomosis was done using a stapling device. The rest of the bowel was healthy with no evidence of necrosis or ischemia. Postoperative hospital course was uneventful and he was advanced to a regular diet on the third postoperative day and discharged home on the fourth postoperative day.Gross pathology of the specimen revealed a firm, extraverted, elongated invagination into the ileum measuring 5.5 cm in its greatest dimension, covered with a smooth mucosal lining on the luminal surface with an irregular fatty tail of tissue on the serosal surface Figure . The cut surface of the mass was firm and yellow in color Figure .Microscopic examination showed benign fat and incorporated heterotopic pancreatic and gastric tissue with no atypical or dysplastic features. Follow-up course was unremarkable Figure .Small bowel obstruction is one of the most common reasons for acute abdomen emergencies and is likely to involve a surgical admission. Bowel obstructions are commonly caused by postoperative adhesions, neoplasms, hernias, volvulus, intussusception, or inflammatory bowel diseases. If not treated promptly, bowel obstruction can lead to acute intestinal dilatation and perforation with consequent faecal peritonitis, sepsis, and multiple organ failure, which have high morbidity and mortality. One of the uncommon causes of bowel obstruction is intussusception (telescoping), when a loop of the small bowel with its mesentery invaginates into the lumen of the bowel segment distal to it. Although it is a common abdominal emergency in children younger than two years of age, it is unusual in adults and the diagnosis is commonly overlooked. Adult intussusception represents 1% of all bowel obstructions, and 0.003%-0.02% of all hospital admissions . In one Neither study clearly showed the true incidence of Meckel’s diverticulum as a cause of adult intussusception. Ectopic tissue such as gastric or pancreatic mucosa is found in about 50%-57% of patients with Meckel’s diverticulum. This could be explained by embryologic origin and the development of midgut. Rutherford et al. studied 147 surgical specimens and found heterotopic tissue in 57%. The types of ectopic tissue found were gastric, pancreatic, colonic, jejunal, and duodenal [Usually, the mechanism of bleeding is the ulceration of the adjacent anti-mesenteric wall of the small bowel due to acid secretion by the ectopic gastric mucosa within the diverticulum, but not from the mucosa or ectopic tissue within it. Intestinal obstruction is another common complication most commonly seen in adults and may be caused by volvulus of the small bowel around a diverticulum, intussusception, or incarceration of the diverticulum in a hernia (Littre′s hernia) and enterolith formation in the diverticulum. Meckel’s diverticulitis most commonly presented as acute appendicitis usually accounts for 10%-20% of complications and is more common in older patients. Benign as well as malignant diverticulum neoplasm also have been reported as a complication of Meckel’s diverticulum. Common benign neoplasms include lipoma, leiomyoma, neurofibroma, and angioma, while malignant tumors include leiomyosarcoma and carcinoid, which represent about 80% of such lesions while adenocarcinoma and metastatic lesions constitute the remainder. Identified over a 15-year period, only 15 patients presented with complicated Meckel’s diverticulum. Inflammation (20.0%), obstructive ileus (20%), intussusception (13.3%), perforation (26.7%) and strangulated Littre’s hernia were most common complications [Although Meckel’s diverticulum is the most common congenital anomaly of the small bowel, inversion or invagination of the diverticulum is a rare occurrence and, if detected, warrants surgical management due to high risk of complications such as ileo-ileal intussusception. To date, there are only a few reported cases in the literature that clearly demonstrate inverted Meckel’s diverticulum as a lead point in bowel ‘telescoping’ and subsequent bowel obstruction. Inverted Meckel’s diverticulum also presents clinically as lower gastrointestinal bleeding, chronic abdominal pain, or with symptoms and signs suggestive of small bowel obstruction. The most common age group of presentation is among young adults unlike Meckel’s diverticulum, and generally present as subacute or chronic symptoms including abdominal pain or low-grade small bowel obstruction .Initial workup in patients with clinical signs of obstruction includes abdominal X-ray, which may suggest nonspecific bowel pattern. Barium studies have been reported to diagnose this pathology in around two-thirds of patients with inverted Meckel’s diverticulum. Specific findings seen on barium examination include elongated smoothly marginated intraluminal mass parallel to the long axis of the bowel. Inverted bulbous tip produces a characteristic club-like appearance seen in more than 90% cases. This finding is due to mesenteric fat filling at the tip of the inverted sac. CT findings are characteristic for central area of fat attenuation surrounded by a thick collar of soft tissue attenuation .Meckel’s diverticulum can invert into the intestinal lumen, and there are reported cases; however, the exact mechanism is not clearly understood. We hypothesized that persistent ectopic tissue may cause abnormal peristaltic movement that subsequently might invert the diverticulum. Once inverted, it can serve as a lead point for further telescoping culminating in an intussusception, intestinal obstruction, segmental ischemia, or even perforation. Preoperative diagnosis of inverted Meckel's diverticulum may be challenging due to overlapping clinical and imaging features of other surgical conditions of the abdomen. And clinicians should keep this rare entity in mind while evaluating patients presenting with signs and symptoms of intussusception to avoid excess morbidity.


Giant cell tumors (GCTs) are typically found in the metaphyseal-epiphyseal area of long bones but can also occur in the head and neck region. GCT of the larynx is a rare entity with only 42 reported cases in the international literature. Furthermore, to the best of our knowledge this is the largest laryngeal GCT reported in the literature to date. GCT of the larynx can present with dysphonia, dyspnea, and/or dysphagia and should be considered in the differential diagnosis of a neck mass.This case report describes a giant cell tumor of the left thyroid cartilage in a 30-year-old man who initially presented with dysphonia and dysphagia. Computed tomography (CT) revealed a 5 × 5.7 cm mass centered on the left thyroid cartilage, which was further diagnosed by histopathology as giant cell tumour by open biopsy. The patient was counselled on treatment options and it was decided to proceed with a surgical approach. The patient consented to and successfully underwent a total laryngectomy (TL). Currently the patient has no evidence of disease at 13 months follow-up, has an optimal prosthetic voice, and is able to tolerate all textures of foods.GCTs of the larynx have a good prognosis and can be treated successfully through complete resection of the tumor, negating the need for adjunctive therapy such as radiation, chemo or denosumab therapy. GCT of the cartilaginous structure of the larynx is a rare entity. To the best of our knowledge, there have only been 42 reported cases in the international literature, including Wessely’s first documented case in 1940 . This isA 31-year-old Bosnian male with an unremarkable health history was originally seen in early October 2015 at a walk-in medical clinic after he noticed a change in his voice for 3 weeks. The patient had no smoking history, no prior occupational exposures, was an infrequent social drinker and worked as an assistant manager at a convenience store. Initially he thought the hoarseness was secondary to an upper respiratory tract infection and surprisingly did not notice the neck mass until it was pointed out to him  than females (n = 4) and have an average age at presentation of 44.6 years [n = 32) followed by cricoid cartilage (n = 9), and epiglottis (n = 2). The size of the tumors were measured by either gross examination or medical imaging. The average tumor size for the reported cases is 3.9 cm. The most common treatment is surgical resection (n = 29) followed by surgery and radiation therapy (n = 4), radiation therapy alone (n = 3), surgery with chemo and radiation therapy (n = 2), surgery plus denosumab (n = 2) and surgery with chemo (n = 1). The average follow-up period for those reported is 4.3 years. All cases that reported follow-up had no evidence of disease with the exception of Swanson and Brown, who reported observing a small subepiglottic nodule at 0.8 years follow up [Based on our case and review of the literature, laryngeal GCTs occur more frequently in males  as a treatment option for GCT of the bone . HoweverAt present the literature supports surgical management of laryngeal GCTs. However, there is an evolving role for novel therapeutics such as denosumab to potentially minimize the morbidity of treatment. Factors that will influence the extent of surgery (TL vs. PL) include: 1) potential recurrence 2) post-operative function and quality of life and 3) if one does choose to do a PL, then management would more likely include ancillary measures such as radiation therapy, chemotherapy, or additional salvage surgery. Furthermore, given the fact the average age at presentation is 44.6 years gives all the more reason to avoid radiation therapy as sarcomatous transformation is of concern .GCTs of the larynx are benign tumors and have a seemingly high cure rate. The main management dilemma is focused upon the extent of laryngeal surgery i.e. laryngeal preservation. There is paucity in the literature related to functional outcomes and quality of life as factors in deciding upon management. With respect to this, surgeons need to be more diligent in reporting follow-up relating to laryngeal function and patient quality of life. With patient counselling and consent, a TL is an effective treatment for an extremely large laryngeal GCT with significant invasion of surrounding tissue. Thus fulfilling the goals of guaranteeing a low recurrence rate and negating the need for adjunctive therapy such as radiation, chemo, or denosumab therapy and their potential complications.