Lipoleiomyoma is a rare, benign variant of the commonplace uterine leiomyoma. Unlike leiomyoma, these tumors are composed of smooth muscle cells admixed with mature adipose tissue. While rare, they are most frequently identified in the uterus, but even more infrequently have been described in extrauterine locations.We describe a case report of a 45-year-old woman with a history of in vitro fertilization pregnancy presenting 6 years later with abdominal distention and weight loss found to have a 30-cm intra-abdominal lipoleiomyoma. While cross-sectional imaging can narrow the differential diagnosis, histopathological analysis with stains positive for smooth muscle actin, desmin, and estrogen receptor, but negative for HMB-45 confirms the diagnosis of lipoleiomyoma. The large encapsulated tumor was resected en bloc. The patients post-operative course was uneventful and her symptoms resolved.Lipoleiomyoma should be considered on the differential diagnosis in a woman with a large intra-abdominal mass. While considered benign, resection should be considered if the mass is symptomatic, and the diagnosis is unclear or there is a concern for malignancy. Lipoleiomyoma is a rare, benign variant of uterine leiomyoma –3. ClassA 45-year-old woman presented to her gynecologist with 6 months of increasing abdominal cramping and marked distention despite a 35-pound intentional weight loss. She denied other systemic or gastrointestinal symptoms. Her medical history was notable for in vitro fertilization resulting in twin pregnancy 7 years prior. She was otherwise healthy with a body mass index of 27 and not taking any medications. Physical examination was remarkable for a non-tender, but firm and distended abdomen with palpable findings suspicious for a large mass. Lower extremity edema was not identified in either leg suggesting that the mass was not compressing the iliac veins and likely superior to the pelvis. All laboratory testing, including serum hCG, was within normal limits.Computed tomography (CT) scan of the abdomen and pelvis revealed a large heterogeneous, hypodense mass measuring 27 cm x 20 cm x 13 cm with irregular, central solid-enhancing components  are retroperitoneal –11. HereThe etiology of the lipoleiomyoma is unknown; however, several hypotheses have been proposed. Most widely accepted is lipomatous metaplasia of muscle cells, suggesting perhaps lipoleiomyoma lies on a continuum with leiomyoma , 8, 11. While the number of cases of lipoleiomyoma remains limited, the tumor is generally considered benign, without the risk of local recurrence or distant metastasis after resection. In contrast, an isolated case report has demonstrated leiomyosarcoma arising from an uterine lipoleiomyoma, suggesting malignant transformation may be possible . SubsequThe management of intraabdominal lipoleiomyoma is typically surgical resection. Unfortunately, most patients present with very large tumors given that these tumors push but not invade surrounding structures, and patients do not seek medical consultation until they are symptomatic. This is also typical of patients with retroperitoneal sarcomas which are known to have a median size of 20cm at presentation . PatientTogether, our case report suggests that although rare, lipoleiomyoma should be considered in the differential for intraabdominal masses and resection effectively treats the tumor. Additionally, our case is aligned with previous reports which suggest that a hyperestrogenic state may play a role in the pathogenesis of lipoleiomyoma; however, further study is needed to better define the origin of these rare tumors.


Umbilical hernia, one of the most frequent pathologies in pediatric surgical practice, is usually corrected with a relatively simple intervention, except in cases where there is a major defect, also called proboscoid hernia. We present a case report of a 20-month male patient that underwent surgical intervention of a giant umbilical hernia with the “Lazy-M and Omega” flap novel surgical technique. This technique has to be taken into account in surgical planning, since it is simple and easily reproducible. Severalet al. . We presA patient with no personal or family history of interest, is seen in consultations from birth due to a large umbilical hernia. Physical examination revealed a soft abdomen, depressible, not painful, without masses or visceromegaly, with an umbilical hernial defect of approximately 3 cm in diameter and an excess of skin of approximately 5 cm in length. After a year and a half of follow-up and seeing that the umbilical hernia was increasing in size and due to the large excess of soft tissue, we decided to include him on the waiting list for surgical correction of the hernia.At 20 months of age, the patient underwent surgery. Already on the operating table, two letters are drawn on the leftover skin. An open “M” through the infraumbilical area  A and thet al. [The umbilical hernia is a common problem in children. A large one often requires umbilicoplasty for a protruding umbilicus with redundant skin. The proboscoid variety of umbilical hernia protrudes through the fascial defect . For moset al. . In thisIn cases such as the one presented with a giant umbilical hernia, the “Lazy-M and Omega” flap is a technique to be taken into account in surgical planning, since it is simple and easily reproducible.


Uterine papillary serous carcinoma (UPSC) is a rare endometrial neoplasm with high mortality rates. While the malignancy has often metastasized to distant organs by the time of diagnosis, brain lesions are extremely rare and most commonly only observed in widely disseminated disease. Here, we present an unusual case of UPSC with brain metastasis discovered six years after undergoing treatment for stage IIIA disease. Compared to the few previous cases of brain metastasis from UPSC, this lesion exhibited unusual imaging characteristics. We also highlight a potential imaging interpretation pitfall which was associated with this case. A 57-year-old female presented to the Emergency Department with blurry vision and slight vertical diplopia that developed gradually over several days. Her history was notable for FIGO stage IIIA uterine papillary serous carcinoma (UPSC) treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, chemotherapy, and radiation therapy six years earlier. She had since been stable and received regular biannual follow-up with gynecological oncology with no evidence of recurrence. She had no other major medical problems and took no medications. Physical exam was unremarkable except for visual acuity of 20/50 OU, OS, and OD. Neurological exam was normal without evidence of cranial nerve palsies.A non-contrast head CT revealed an extra-axial hypodense mass within the quadrigeminal cistern measuring approximately 1.5 × 1.2 × 0.9 cm with mild mass effect upon the tectum and anterosuperior cerebellum .Subsequent brain MRI with and without gadolinium contrast was significant for a multilobular, heterogeneous, primarily hyperinstense T2 lesion within the quadrigeminal cistern with extension into the ambient cisterns . The lesDifferential diagnosis for intracranial extra-axial lesions may include neoplasms, developmental cysts, and infectious/inflammatory cause like sarcoid, hemorrhages, and vascular abnormalities. The mass did not demonstrate blooming artefact on the SWI sequence, which ruled out hemorrhage. Appearance and location would also be unusual for an extra-axial bleed. While conventional T1W post-contrast images demonstrated mild heterogeneous enhancement, it was very subtle and the lack of significant enhancement on FSPGR images or pulsation artefact ruled out possible aneurysms or other vascular malformations. The lesion did not follow CSF signal on all sequences, which ruled out an arachnoid cyst. A dermoid cyst was considered although less likely as the mass demonstrated intermediate T1 signal without the typical T1-shortening seen in fat-containing lesions. Metastatic disease was initially thought less likely given lack of significant enhancement, unusual location and the fact that it was a solitary lesion. An atypical epidermoid cyst was suggested as the most likely diagnosis given incomplete signal drop out on FLAIR sequences and lack of true restricted diffusion. Neurosurgery was recommended for tissue diagnosis given absent characteristic imaging findings for a specific mass as well as the patient’s vision loss.The patient underwent craniotomy with near gross total resection of the lesion. Pathology results indicated a papillary carcinoma, favoring metastatic UPSC given its immunoreactivity to PAX8 and her clinical history. She was referred to gynecologic-oncology, medical oncology, and radiation oncology. Six weeks after surgery, brain MRI revealed the residual small septated cystic mass centered in the quadrigeminal cistern and left ambient cistern. After subsequent PET scan did not reveal evidence of disease elsewhere, decision was made to treat with radiation therapy and chemotherapy was deferred.The patient tolerated radiation therapy well which resulted in interval reduction of her intracranial mass. She is on a surveillance plan of annual PET scans and head/spinal MRI’s every 3–4 months. She also receives follow-up with gynecologic oncology, radiation oncology, and neurosurgery every 3–4 months and is overall doing well seven months after her diagnosis was confirmed by pathology.1 It has a higher rate of abdominal and systemic recurrence and lower rates of survival when compared to endometrioid endometrial carcinomas (EEC), the most common form of cancer in the female reproductive tract.2,3 Brain metastasis from endometrial cancer is extremely rare, accounting for 0.6% of cases from a review of over 10 000 patients.4 A review by Sierra et al5 in 2015 identified nine cases of UPSC that elicited brain metastasis, a 2015 case series by Narasimhulu et al6 described two more and a 2019 case report by Filho et al7 described another. This appears to be the thirteenth that has been reported.While only accounting for 10% of endometrial cancers, UPSC accounts for 39% of its deaths.5,8 Also unusual was her brain mass being the solitary metastatic lesion. Metastatic UPSC is usually found in the brain only in widely disseminated disease, and only four of the other twelve cases exhibited this characteristic.4,5,9,10 Finally, this patient is notable for her relatively successful clinical outcome for a highly malignant form of endometrial carcinoma. Average survival after diagnosis of a brain metastatic lesion from UPSC was found to average five months in the first nine reported cases by Sierra et al. and only one of the other eleven cases was alive at the time of case write-up.5 At the time of this case’s submission, it has been 14 months following her initial CT scan and she continues to do well.This patient’s case was notable for its long interval from primary diagnosis to identifying brain metastasis. Only one other case out of the thirteen exhibited this interval greater than five years.5 The cases varied between solitary and multiple brain lesions. Second, this case appears to be the first reported to not display a strong element of post-contrast enhancement. As described above, while conventional post-contrast images did display mild heterogeneous enhancement, FSPGR images did not enhance significantly. Contrast enhancement was noted in cases presented by Narasimhulu et al6, Filho et al7, Gulsen et al11, and Sierra et al5. Finally, the mass in this case had a heterogeneous appearance on all sequences, differing from cases presented in Filho et al7, Sierra et al5, Narasimhulu et al6, and Gulsen et al11, which were homogeneous.The imaging findings were notable for several reasons. First, it appears to be the first reported lesion in the quadrigeminal cistern. Of the eight prior cases in which location was described, lesions were intra-axial and found in the frontal, occipital, temporal, and parietal, regions as well as the cerebellum.12,13 This was evident in our case as shown in the images above. There was no significant enhancement shown in our FSPGR images, while our conventional spin-echo images showed mild heterogeneous enhancement. This serves as a reminder that although there are advantages to gradient-echo sequences, spin-echo is preferred for capturing the full spectrum of contrast-enhancing lesions within the central nervous system.12 Thin slices obtained by 3DFSPGR sequences can mitigate this potential pitfall.13Chappel et al., Furutani et al., and others described that interpretation of images obtained by gradient-echo sequences has the potential to miss findings more easily visualized with spin-echo sequences.The explanation for the mass’s unusual location and imaging characteristics is unclear. Given the low sample size of cases demonstrating metastasis to the brain, it is difficult to confidently describe what the characteristic imaging appearance should be. The difference in presentation from the prior cases only adds to our general knowledge and should heighten our awareness of the variability of presentation as opposed to the previously reported cases of an intra-axial, strongly enhancing homogenous mass.Uterine papillary serous carcinoma (UPSC) accounts for only 10% of endometrial cancers but 39% of its deaths.Endometrial cancer with brain metastasis is extremely rare, occurring in only 0.6% of cases. This patient appears to be the thirteenth reported case demonstrating the rare phenomenon of UPSC metastasizing to the brain.Based on the limited data from previous cases, metastatic UPSC to the brain typically presents as an intra-axial lesion has a homogeneous appearance on all MRI sequences, and normally strongly enhances with contrast administration. This case was unusual in that it differed in each of these characteristics.Spin-echo is normally superior to gradient-echo in detecting contrast-enhancing lesions, despite the advantages of gradient-echo sequences. Thin slices of 3DFSPGR sequences mitigate this potential pitfall.


Cyst-like lesion in the coronoid process of the mandible is a challenging diagnosis to make, as it may present with a range of non-specific symptoms. A middle-aged woman reported a one-year history of non-bloody, pus discharge from the right angle of the mandible. There was a history of prior surgery comprising teeth removal two years ago for a painful swelling on the right side of her face, following which her symptoms regressed but in the due course, she developed a chronic sinus with draining abscess. Radiographic findings, in combination with clinical symptoms, are critical in the diagnosis and evaluation of cysts and cyst-like lesions of the jaws. The orthopantomograph (OPG) revealed a cyst-like lesion in the coronoid process of the mandible with an extra-oral sinus tract leading to the epicenter of the cyst-like radiolucency, and so this, in combination with the patient’s atypical symptoms, presented a diagnostic challenge. This case report explores the events which led to the diagnosis of osteomyelitis and shows several unique learning points. The presentation of a cyst-like lesion in the coronoid process of the mandible is rare and not commonly associated with an extra-oral sinus tract. Diagnosis in such cases is challenging for clinicians. Radiographic findings, in combination with clinical symptoms, are critical in the diagnosis and evaluation of cysts and cyst-like lesions of the jaws. Making a differential diagnosis based on the radiographic studies can negatively affect the treatment planning process because mandibular lesions may arise from both odontogenic and nonodontogenic origins. Since both odontogenic and nonodontogenic lesions mimic each other with similar radiological appearances, diagnosis may become challenging . This arA 45-year-old female reported to the outpatient clinic, for evaluation of an extra-oral cutaneous fistula on the right angle of mandible draining pus for the past 18 months  revealed a well-defined radiolucency in the right coronoid process along with multiple grossly decayed teeth Figure .The cutaneous fistula did not open into the oral mucosal lining and hence a gutta percha point was used to trace the fistulous tract and an OPG was repeated. The tracer gutta percha point measuring 3 cm was abutting the right hemi-mandibular osseous defect Figure .Cone beam computed tomography (CBCT) showed a focal smooth marginated cortical defect in the right hemi-mandible involving the mandibular notch extending to the base of the adjacent coronoid process. It measured 16 mm x 11 mm , and the overlying cortex appears to be thinned out at places. Focal cortical defect opened laterally into the adjacent soft tissue and the peri-focal mandibular ramus appeared sclerotic. The ill-defined soft tissue thickening around the cutaneous defect overlies the right angle of the mandible. The radiographic features along with the clinical features suggested an infective etiology in the right hemi-mandible. MRI was suggested to evaluate for osteomyelitis Figure .Extraction of 43, 44 and 45, followed by antibiotic therapy with oral ciprofloxacin and ornidazole 500 mg BD, did not resolve the pus discharge and was futile. The surgeon went ahead with the surgical excision of the right coronoid process without performing the MRI because of cost, feasibility, and additional time for the patient.Anemia was addressed by performing a blood transfusion during the pre-anesthetic evaluation. A right coronoidotomy along with full mouth extraction was performed under general anesthesia and the specimen was sent for histopathological evaluation Figure .Histopathologic examination showed dense connective tissue stroma with evidence of several foci of chronic inflammatory cell infiltrate along with many endothelial cell proliferation and few Russell bodies. Evidence of an area of epithelial nest suggestive of the juxtaoral organ of Chievitz was observed. The decalcified section of bone showed mature trabeculae of lamellar bone with lacunae devoid of osteocytes along with a few chronic inflammatory cell infiltrates and several areas of hemorrhage Figure .The histologic and radiographic patterns were consistent with the chronic type of osteomyelitis. Intravenous cefotaxime 1 g BD, metronidazole 500 mg TID, and paracetamol 1 g BD were administered for three days. She has had regular clinic follow-ups since diagnosis and has noted obliteration of the cutaneous fistula Figures -9.Post-surgical OPG reveals resolution of the lesion and is fit to undergo prosthetic rehabilitation of the missing teeth Figure .Osteomyelitis is a rare, inhomogeneous condition with a varied clinical picture causing potential functional impairment or permanent disability in severe cases. It refers to inflammation of the entire bone, inclusive of the periosteum, cortical and cancellous bone, along with bone marrow. Many classifications exist based on etiology, pathology, anatomical variations, clinical course or radiologic pattern, which makes the comparison between different types hard.The Zurich classification is recognized as the most reliable classification system which classifies as acute osteomyelitis, secondary chronic osteomyelitis, and primary chronic osteomyelitis . Acute oThere are multiple etiologies for osteomyelitis, including inoculum of bacteria, trauma, ischemia, or foreign bodies. Incidence of infection depends on the local immune response of the host, virulence, and load of bacteria, and blood flow to the tissues. In our case, the patient also gave a history of anemia, which is a potential risk factor in the development of osteomyelitis. The bacteria contaminate the bone and proliferate and multiply in the bone marrow. It reaches the periosteum through the Haversian and Volkmann canals forming an edema, which hinders blood flow to the bone and subsequently builds a sequestrum -4.Secondary chronic osteomyelitis is currently considered the most frequent form of osteomyelitis with an incidence of 70% while the incidence rate of acute osteomyelitis is 17% and primary chronic osteomyelitis is 10%. There is a surge in incidence because of the advances in diagnostic imaging techniques. Plain radiography, like panoramic radiograph, is the first-line imaging test in suspected osteomyelitis, as it gives simultaneous information of the maxilla and mandible and aids in identifying and excluding differentials like a fracture. It plays a pivotal role in diagnosing osteomyelitis, although it cannot diagnose the condition independently -6.Radiographically, osteomyelitis is confirmed by the increase in thickness of lamina dura of alveolus, sclerotic variation around the mandibular canal, sclerotic variation of the maxillary bone, and simultaneous destruction and resorption of bone tissue and pattern. But, discovering such signs may be questionable at an early stage of four to eight days after onset of osteomyelitis . ParadoxMRI demonstrates bone marrow edema, confirms abscesses, and delineates extra-osseous disease spread. MRI, being the best imaging modality for establishing the diagnosis, was not performed considering the feasibility and additional cost for the patient -9.The goal of the therapy is to treat the infection with antibiotics and improving the local blood flow by removing the infected bone ,10. TreaTherapeutic success is characterized by a symptom-free state after the intervention. Acute and chronic osteomyelitis have a success rate of approximately 75%. Early treatment, including antibiotic therapy, is necessary to prevent the development of complications like septic arthritis, pathological fractures, squamous cell carcinoma, amyloidosis (rare), bone deformity, systemic infection, and contiguous soft tissue infection . FollowiThis case shows the utility of the imaging modalities to better diagnose osteomyelitis so that treatment options can be introduced at an earlier stage. In the end, biopsy is considered the gold standard. The early detection of osteomyelitis is critical since treatment options are currently available with the goal of improving the quality of life in affected patients. Current research has shown promise that the aforementioned imaging modalities may also help assess response to therapy. Initially, the lesion was thought to be cyst secondary to odontogenic or nonodontogenic cysts, but the development of imaging, CT scanning revealed focal cortical defect opening laterally into the adjacent soft tissue and a sclerotic perifocal mandibular ramus. Understanding the information got from radiologic studies and correlating them with clinical symptoms is a critical step in diagnosing and which surgical procedure is necessary.


Glioblastoma belongs to the most common and most aggressive tumor entity of the central nervous system with a poor prognosis of only few months. Once manifested, it grows fast and diffusely by infiltrating the surrounding brain parenchyma. Despite its aggressive behavior, glioblastoma rarely presents with multiple lesions and metastasis to intra- and extracranial tissues. Therefore, metastasized, multiple glioblastoma is limited to case reports. Our case describes an atypical primary bilateral manifestation of BRAF V600E-positive epithelioid glioblastoma with rapid metastasis and meningeosis glioblastoma while under adjuvant chemoradiotherapy.O6-methylguanine-DNA methyltransferase methylation (MGMT) at 12%. While being under the adjuvant chemoradiotherapy with temozolomide, the patient developed left-sided facial nerve weakness and hearing loss, dysarthria, and severe gait instability. Cranial magnetic resonance imaging showed that glioblastoma lesions advanced rapidly with a schwannoma-like growth pattern by invading the left internal acoustic meatus, adjacent cranial nerves, and leptomeninges. A lumbar puncture confirmed meningeosis glioblastoma. Four months after the initial diagnosis of glioblastoma, the patient died from the complications of the fast and diffuse metastasis.A 60-year-old Caucasian male patient presented with a seizure and numbness in his left arm. He was diagnosed with an abnormal primary bilateral manifestation of multiple, multifocal BRAF V600E-positive and isocitrate dehydrogenase (IDH) wild-type intracranial epithelioid glioblastoma with Glioblastoma rarely presents with metastases despite its aggressive and rapidly growing nature. Our case should increase awareness of symptom tracking in patients with glioblastoma to intervene early and efficiently. Moreover, refractory therapies for glioblastoma should underline the importance of personalized medicine. In particular, cases of refractory therapies necessitate the development of novel therapeutic algorithms. Finally, yet importantly, our case alludes to rare cases and their radiological presentation, thus improving the diagnostic workup overall. Should the left-sided lesion be regarded as a potential metastasis, a different therapy approach should be planned, for example, whole-brain rather than stereotactic radiotherapy.


Chilaiditi sign is a rare incidental radiographic finding where bowel is interposed between the diaphragm and the liver, often seen as air under the right hemidiaphragm. A majority of patients with Chilaiditi sign are asymptomatic and remain so throughout their lifetime. Chilaiditi sign is recategorized as Chilaiditi syndrome if it becomes symptomatic and is a very rare etiology of bowel obstruction. As bowel obstruction confers a huge financial burden to the health care system, studies of even the rarer etiologies are of significant value. Particularly in the case of Chilaiditi syndrome, the free air under the right hemidiaphragm can lead physicians to prematurely conclude pneumoperitoneum, which would require an emergent surgical evaluation. It is through the incorporation of a broad differential and clinical presentation that physicians can decrease the inappropriate allocation of hospital resources and unnecessary surgical procedures; additionally, keeping Chilaiditi syndrome on the differential may prevent unnecessary surgical intervention, cost to the patient, and downstream complications. Bowel obstruction secondary to Chilaiditi syndrome is most commonly treated with conservative management including intravenous fluids, bowel rest, decompression, and laxatives. If the symptoms worsen and progress to full bowel obstruction, surgical intervention has shown great efficacy. We report a case of a 69-year-old male who presented to the emergency department for progressively worsening abdominal pain, nausea, and vomiting incidentally found to have colonic interposition with mild colonic dilatation on computed tomography (CT) imaging. The patient was diagnosed with bowel obstruction secondary to Chilaiditi syndrome and treated non-surgically with rapid recovery. There are an estimated 300,000 hospitalizations per year secondary to intestinal obstruction in the United States, which accounts for approximately 15% of all emergency room admissions. Annually, the financial burden of intestinal obstruction on the healthcare sector is approximately three billion dollars .Signs of bowel obstruction include abdominal distention, nausea, vomiting, diarrhea, inability to pass flatus, constipation, loss of appetite, and abdominal pain. Differentiation of small bowel obstruction (SBO) and LBO via clinical presentation alone may be difficult due to overlapping signs, but quality, timing, and presentation can aid in distinguishing between the two; the abdominal pain in LBO is typically continuous and more diffuse, whereas pain secondary to SBO is more colicky and focal in nature. The vomiting that accompanies SBO tends to be more voluminous, bilious, and more frequent than that of LBO. Additionally, the abdominal distention is more marked in LBO than in SBO .The workup for a patient who presents with signs or symptoms of intestinal obstruction includes determining if the patient is clinically stable and performing imaging to see if findings are consistent with obstruction; instability or any indication of vascular compromise, perforation, or closed-loop obstruction are indications for emergent surgical evaluation or operative exploration. A hallmark finding for bowel viscus perforation is pneumoperitoneum - free air under the diaphragm on chest x-ray kidney, ureter, and bladder x-ray (KUB). This, however, should not be the sole determining factor for the determination of need for surgical intervention as there are other causes for air under the diaphragm. One such example is Chilaiditi sign - a benign radiological finding with an incidence of 0.025-0.28%, which describes the interposition of a part of the bowel between the diaphragm and the liver, a finding that can be misinterpreted as pneumoperitoneum ,4. The cThe exact cause of Chilaiditi syndrome is unknown, but risk factors include abnormal elongation of the colon, laxity of ligaments in the colon and liver. It has been noted to occur in individuals with chronic lung disease, cirrhosis, and ascites at a greater frequency. Additionally, Chilaiditi syndrome is associated with irritable bowel diseases and Ogilvie syndrome (pseudo-obstruction) . It is tA 69-year-old male with a past medical history remarkable for diverticular disease and gastroesophageal reflux disease presented to the emergency department for progressively worsening abdominal pain. The pain was colicky in nature and diffuse. The patient endorsed nausea and a two-day history of constipation. He stated that he was unsure whether or not he passed flatus since the pain started. Upon interview, the patient expressed that he has had similar episodes in the past to a lesser extent. He has no significant past surgical history. He is a non-smoker and drinks two alcoholic beverages per day. The patient had a temperature of 99.4˚F, a heart rate of 88 beats per minute, a blood pressure of 115/84 mmHg, and was tachypneic at 22 breaths per minute.On physical examination, hyperactive bowel sounds, moderate abdominal distention, and diffuse abdominal tenderness were appreciated. The abdominal tenderness was worst in the right upper quadrant and Murphy’s sign was negative. The pain and nausea worsened when lying supine compared to seated or standing. A right-sided direct inguinal hernia was appreciated, reducible, non-tender, and non-indurated. A complete metabolic panel showed hyponatremia with a serum sodium concentration of 132 mEq/L and a slightly elevated aspartate aminotransferase (AST) of 62 u/L with the rest of the studies within normal limits. Lipase and a complete blood count were also within normal limits. An electrocardiogram showed normal sinus rhythm. A chest x-ray was performed, which was of poor quality due to patient movement, and demonstrated a potential small quantity of air under the right hemidiaphragm. CT scan of the abdomen and pelvis without contrast demonstrated two hypodense lesions in the liver suspicious for cysts, a small hiatal hernia, submucosal fat deposition in the cecum, ascending colon, and transverse colon that favors chronic inflammatory bowel disease, and colonic interposition with mild proximal dilation . He was afebrile throughout the entire admission and treated conservatively with intravenous fluids but refused nasogastric tube decompression. The patient was unable to have a bowel movement, but he was able to produce flatus. The patient agreed to a trial of magnesium citrate which yielded a large bowel movement, which significantly reduced the distention and resolved his other symptoms. The patient was able to tolerate a meal and was later discharged to home.After initial assessment of hemodynamic stability, patients presenting with symptoms consistent with intestinal obstruction are initially worked up through a hierarchy of imaging modalities to assess the cause and need for surgery. Initial plain radiographs may show air below the dome of the right diaphragm. Surgeons unfamiliar with Chilaiditi sign may immediately interpret this as pneumoperitoneum and undergo further surgical exploration without further exploring other differentials, exposing patients to a myriad of potential unnecessary complications when conservative measures may suffice. Given the risks of surgery, clinicians and surgeons should keep a broad differential for air under the diaphragm including subphrenic abscess, intestinal pneumatosis, pneumoperitoneum, and Chilaiditi syndrome among others, especially when the clinical picture does not align with these other working diagnoses.The main goal when this radiographic finding is noted should be to assess whether the subdiaphragmatic air is free or intraluminal. For instance, if air has accumulated in the large intestine, haustral folds should be visualized and air should be unaffected by positional changes. However, if air has instead accumulated in the peritoneal cavity, a second radiograph with positional changes should reveal air movement. If there is doubt, confirmation can be obtained by CT, which was what occurred in the case of this patient.There are many potential implications of failing to account for Chilaiditi sign. Misdiagnosis as bowel perforation may expose patients to potential surgical complications. On the one hand, in cirrhotic patients, a failure to recognize Chilaiditi syndrome may lead patients who are undergoing percutaneous transhepatic procedures or liver biopsies to potentially puncture the intestine. There is also increasing evidence that pursuing colonoscopy in these patients can lead to perforation caused by the increased risk of air entrapment in angulated, interposed bowel. Thus, failing to account for colonic interposition may unnecessarily result in a wide array of complications.Intestinal obstruction places a substantial financial strain on the healthcare system. It is important both in terms of appropriate allocation of resources and patient outcomes to consider a broad list of differential diagnoses that include more uncommon etiologies. Chilaiditi syndrome is of particular importance as it can often be confused with pneumoperitoneum, potentially leading to an unnecessary surgical evaluation and intervention that may precipitate other sequelae. It is of equal importance to understand how Chilaiditi syndrome may present clinically and predispose to bowel obstruction, which may aid in the prevention of hospitalizations. Further, knowledge of associated conditions and complications for this condition may provide more insight into who is at risk and guide therapeutic options. Further investigation into the etiology, risk factors, clinical presentation, and complications is therefore warranted. A greater body of research literature on this condition will undoubtedly lead to an improved ability to accurately diagnose and manage it while also promoting an optimized use of hospital resources.


Musculoskeletal symptoms related to orthopedic conditions are highly prevalent worldwide and are a leading cause of morbidity. However, non-orthopedic conditions may also present with musculoskeletal symptoms. For example, shoulder pain may be caused by gastrointestinal, hepatobiliary, cardiac, and neurological pathologies. We report the case of a 32-year-old man who presented to the orthopedic clinic with a complaint of left shoulder pain for the past three months. He described the pain as sharp in nature. The pain was constant and was not related to the shoulder movements. It was not associated with morning stiffness. He had no history of preceding trauma. On examination, both shoulders were symmetrical with no evidence of deformities. Palpation over the shoulder region did not elicit any tenderness. The range of motion in both the active and passive movements was intact. The Neer and Jobe tests were negative. Also, the sensory examination was intact, and laboratory findings were normal. The patient underwent a plain frontal radiograph of the chest, which revealed a large well-circumscribed lobulated mass lesion in the left hemithorax, arising from the pleural lining. A thoracic CT scan was then performed to provide further characterization of the mass lesion and it re-demonstrated the mass as having homogeneous fat-attenuation with thin septations, probably representing pleural lipoma. The tumor was successfully resected via open thoracotomy. The patient's symptoms resolved and he had no recurrence after one year of follow-up. Pleural lipoma is a very rare benign mesenchymal tumor. The case highlights the importance of considering non-orthopedic conditions in the differential diagnosis of shoulder pain in patients with normal physical examination findings. A CT scan is vital to make the diagnosis and can show the accurate anatomic relations with respect to the tumor for surgical planning. Musculoskeletal disorders are highly prevalent conditions that lead to a high economic burden on healthcare systems and societies. The Global Burden of Disease study has illustrated that musculoskeletal disorders are the leading cause of non-communicable disease disability . While tA 32-year-old man presented to the orthopedic clinic with a complaint of left shoulder pain for the past three months. He described the pain as sharp in nature. The pain was constant, not related to the shoulder movements, and non-radiating. He scored it as 4/10 on the severity scale. There was no history of preceding trauma, but the patient reported that the pain had worsened after weight-lifting exercise. There had been no change in the severity of his pain and no history of pain in other joints. The pain was not associated with morning stiffness.Apart from a history of mild intermittent asthma, the patient was generally healthy. He had no history of surgical interventions, and he was not taking any medications routinely. He was physically active and maintained a healthy lifestyle. There was no history of smoking or alcohol consumption. The family history was positive for celiac disease in all his siblings. He worked as a computer engineer.On examination, both shoulders were symmetrical with no evidence of deformities. Palpation over the shoulder region did not elicit any tenderness. The range of motion in both the active and passive movements was intact. The Neer and Jobe tests were negative, and the sensory examination was intact. Accordingly, the findings suggested that shoulder pain could be secondary to pathologies extrinsic to the shoulder joint. Examination of the respiratory system revealed decreased air entry over the upper and middle zones of the left lung.The patient underwent basic laboratory investigations. The findings revealed a hemoglobin level of 13.4 g/dL, leukocyte count of 8000/μL, and platelet count of 410,000/μL. The erythrocyte sedimentation rate (10.5 mm/hour) and the C-reactive protein (3.8 mg/dL) levels were within the normal range. The metabolic findings, including hepatic and renal function tests, were not deranged. No further workup was performed to rule out the autoimmune rheumatological disorder.As an initial imaging investigation, the patient underwent a plain frontal radiograph of the chest Figure . The radGiven the large size of the tumor and the patient’s symptoms, he was prepared for the surgical removal of the mass. He was referred to a tertiary center with thoracic surgery facilities. An open left thoracotomy was performed, which revealed a smooth surface tumor arising from the pleura and occupying most of the left thoracic cavity. There was no evidence of invasion of surrounding structures. The entire mass lesion was successfully removed. The diagnosis was confirmed to be pleural lipoma with no evidence of malignant sarcomatous changes. The operation and the recovery were not remarkable for any complications.The patient had his follow-up in the family medicine clinics. He reported significant improvement in his symptoms following the surgery. After one year of regular follow-up, no active issues were reported by the patient to suggest any disease recurrence.We reported a case of a large pleural lipoma manifesting as left shoulder pain. Lipoma is a benign soft tissue tumor arising from mature adipose cells. It can virtually develop in any region of the body. The thoracic cavity is among the uncommon sites for lipoma lesions. In particular, pleural lipoma is exceedingly rare .Considering their slow growth and benign nature, these tumors become symptomatic when they reach a significant size and cause mass effect . In our Pleural lipoma is often detected incidentally on plain chest radiographs. However, a CT scan is the method of choice to provide a detailed assessment of the lesion and surgical planning . The masThe management of pleural lipoma depends on its size and clinical findings . In our Pleural lipoma is a very rare benign mesenchymal tumor. Our case highlights the importance of considering non-orthopedic differential diagnoses of shoulder pain in patients with normal physical examination findings. A CT scan is crucial for the diagnosis and illustrates the accurate anatomic relations with respect to the tumor for surgical planning. The prognosis of the tumor is good with a low recurrence rate if the tumor is completely resected.


Low-grade appendiceal mucinous neoplasms (LAMNs) are papillary or flat mucinous tumors with low-grade cytologic atypia found in <0.3% of appendectomy specimens among older population. They are the most frequent source of pseudomyxoma peritonei. They can be easily misdiagnosed, due to unspecific symptoms, with acute appendicitis, retroperitoneal tumors or adnexal mass. Macroscopically, the appendix may appear normal or be variably dilated. Microscopic study determines whether the studied specimen is LAMN or mucinous adenocarcinomas. We report a 77-year-old patient presented with 15-day abdominal pain accompanied with chills and hyperthermia. Decision was made for right hemicolectomy as a result of the findings on ultrasound and computed tomography scan. Diagnosis was made after the pathologic study, which revealedLAMN. One of the most common types of specimens received in laboratory is vermiform appendices. In juvenile population, most specimens show standard features of acute pyogenic and necrotizing appendicitis, whereas in older population, low-grade appendiceal mucinous neoplasms (LAMNs) should be considered as a differential diagnosis, even they are found in <0.3% of appendectomy specimens, since they can be easily misdiagnosed due to unspecific symptoms like abdominal pain, nausea, vomiting and palpable mass in the right iliac fossa . LAMNs aThese tumors are not uncommon and are the most frequent source of pseudomyxoma peritonei (PMP), a unique peritoneal malignancy characterized by slow growth of tumor in the peritoneal cavity , 8.A 77-year-old patient presented with a 15-day abdominal pain unresponsive to analgesics. He complained of chills and hyperthermia with one peak at night, while he did not mention any change in bowel habits. The patient had no medical history.Clinical examination revealed a tender abdomen and pain located within the right iliac region. No abdominal masses were tangible.Abdominal auscultation indicated a normal bowel motility. Digital rectal examination ‘DRE’ showed stool remaining on the probing finger. The patient had low blood pressure ‘110/70’ with a pulse of 80 beats\min. A number of laboratory tests were made .Echography depicted a dense fluid-filled mass of 10 cm diameter in the right iliac, the wall was not perfused.Computed tomography (CT) scan was performed after perfusion of a radiopaque substance through the vein in both arterial and venous phases. It exhibited a 14-cm lobulated cystic formation in the level of the right iliac vessels with an extension to the upper margin of the pelvis. The wall of the cyst was thick and calcinated .Both echography and CT scan displayed normal findings for other inner organs within the abdominal cavity and confirmed the absence of free fluid.An agreement of the surgical board to perform a right hemicolectomy . The patLAMNs represent a relatively homogeneous group of papillary or flat mucinous tumors with low-grade cytologic atypia analogous to low-grade dysplasia in other parts of the gastrointestinal tract . LAMNs aMacroscopically, the appendix may appear normal or variably dilated. Dilated LAMNs typically show thin fibrous walls with calcification of the wall and/or the intraluminal mucin. Most patients with PMP present with grossly apparent rupture with extrusion of mucus. Severe inflammatory response to mucus might disguise the presence of mucin around the appendix, stimulating ruptured appendicitis .Microscopically, LAMNs were classified when demonstrating low-grade cytologic atypia and minimal architectural complexity, but when demonstrating whether destructive invasion of the appendiceal wall, high-grade cytologic atypia or complex epithelial proliferation, they were classified as mucinous adenocarcinomas . HistoloLAMNs are characterized by frequent KRAS mutations and do not generally show microsatellite instability or BRAF mutation. They also commonly contain GNAS mutations, which are unusual in colorectal neoplasms .LAMNs are associated with diverticula, herniations, dissections, rupture and ovarian mucinous tumors. The most significant complication is seeding of mucin into the adjacent peritoneum, causing PMP .Often, this malignancy is misdiagnosed as acute appendicitis, retroperitoneal tumors in the right iliac fossa or an adnexal mass. Imaging tools used for diagnosis are ultrasound and CT. CT findings include cystic dilation within the appendiceal lumen with wall calcifications and irregular appendiceal wall thickening as demonstrated in our case. Grossly, specimens include hyalinization and fibrosis of the appendiceal wall with a grossly swollen appendix secondary to mucinous accumulation .The optimal approach remains controversial, preferably the surgical approach, adjuvant therapy, follow-up duration and imaging technique. The goal of management of LAMN includes the prevention of rupture, seeding and development of PMP as performed in our case .Overall, further studies are needed for a more definitive method of diagnosis, treatment and monitoring of LAMN. This case presents the importance of developing a high index of suspicion regarding the development of appendiceal malignancies and choosing the appropriate surgical or medical treatment modality to prevent recurrence, seeding, and development of PMP .Conception and design: J.T., A.D. and M.T. Analysis and interpretation of the data: J.T., M.T. and A.D. Drafting of the article: J.T. and A.D. Critical revision of the article for important intellectual content: M.T. and T.A. All authors read and approved the final version of the manuscript.An informed consent was signed by the patient.We have no conflict of interest.There are no funding sources.


This patient had high serum levels of inhibin B and LH but normal levels of FSH and estradiol. The preliminary diagnosis of granulosa cell tumor of the ovary was made. After counseling, the informed consent for treatment was obtained and the patient agreed to undergo surgery. An uneventful laparoscopy was performed with right oophorectomy and multiple peritoneal sampling. The histological diagnosis confirmed adult GCT limited to right ovary, with negative peritoneal biopsies (FIGO IA). After surgery the patient recovered fully and had normal menstrual cycles with normal serum levels of hormones. Two months later she conceived spontaneously and had an uneventful pregnancy. In conclusion, for cases with secondary amenorrhea, the evaluation of inhibin B level is essential. Elevated inhibin B level may be a sign for the presence of an unsuspected tumor. With early diagnosis and treatment, the prognosis is generally good and the fertility may be preserved, especially in young patients with GCT.Granulosa cell tumor of the ovary (GCT) is a rare ovarian tumor with nonspecific symptoms. Studies reported that GCT are usually secreting estrogens and inhibins, especially inhibin B. It is considered that, in premenopausal women, irregular menses or secondary amenorrhea may be an early symptom of GCT and, in postmenopausal women, the most common manifestation is vaginal bleeding. Additionally, endometrial abnormalities can be associated due to estrogenic secretion. At reproductive age, high levels of inhibin, lead to low levels of FSH and secondary amenorrhea causing infertility. At times, increased levels of LH in women with GCT are observed and the pathogenesis is still unclear. Therefore, inhibin B level can differentiate GCT from other causes of secondary amenorrhea. We report the case of a 26-year-old nulliparous, women who presented in our clinic with secondary infertility lasting longer than 2 years, secondary amenorrhea, polycystic ovarian syndrome, and suspicion of right ovarian endometrioma on CT scan. The ultrasound examination revealed that the right ovary was transformed in an anechoic mass with increased peripheral vascularity having a volume of 10 cm Granulosa cell tumor of the ovary (GCT) is a relatively rare ovarian tumor with low incidence, representing 5% of all ovarian cancers . Thus, lIt is believed that GCT are derived from granulosa cells, somatic cells of the sex cords of the ovary. They are responsible for production of sex steroids (estradiol) and proteins (inhibin) important in folliculogenesis and ovulation . ThroughSymptoms are nonspecific, abnormal vaginal bleeding or amenorrhea are the most common ones. A palpable abdominal mass and abdominal pain are frequently seen in patients with GCT ,8,9. AddThere are no specific imaging ultrasound (US) criteria for the diagnosis of these tumors and it is sometimes misdiagnosed as endometrial cyst, especially in cases where infertility is associated . Ko SF eThe standard treatment for GCT is complete surgery consisting of hysterectomy with bilateral salpingo-oophorectomy. Fertility-preserving surgery with unilateral salpingo-oophorectomy with histological staging is an option in young patients with stage IA GCT . ChemothAfter removal of tumor, serological levels of hormones return to normal. Serum levels of inhibin B are useful in the follow-up of granulosa cell tumors .3 and no sign of normal peripheral ovarian tissue or ultrasonographic criteria for polycystic ovaries  was 1.86 ng/mL, luteinizing hormone (LH) 41.9 mUI/mL, FSH 7 mUI/mL, Estradiol 168.5 pmol/L, Testosterone 1.46 nmol/L, Progesterone 1.21 pmol/L, total HCG 1.4 mUI/mL, HE4 56.53 pmol/L, AFP 1.66 ng/mL, CA 125 20.7 mUI/mL, and Inhibin B 200 pg/mL.The preliminary diagnosis of granulosa cell tumor of the ovary was made. After counseling, the informed consent for treatment was obtained and the patient agreed to undergo surgery. A laparoscopy was performed and the right ovary was described as a white incapsulated tumor, without extracapsular disease . The lefThe histopathology report confirmed the clinical suspicion of adult GCT limited to right ovary, with all peritoneal biopsies being negative. The oncology staging was FIGO IA and the patient was given the options for in vitro fertilization (IVF) due to left tubal obstruction with higher rates of success, or conservative management regarding a future pregnancy.For the FIGO IA GCT she was seen by the multidisciplinary team for clinical and imaging monitoring. After surgery the patient recovered fully and had normal menstrual cycles with normal serum levels of hormones. Two months later she conceived spontaneously and had an uneventful pregnancy . The patClinical symptoms for granulosa cell tumors are nonspecific, making the diagnosis difficult and, therefore, delaying the treatment. In young women, secondary amenorrhea usually occurs due to increased levels of inhibin B which subsequently inhibits the secretion of pituitary follicle-stimulating hormone (FSH) . In the Nasu et al. described a case with high level of LH and normal FSH and estradiol levels . AdditioAdditionally, patients with GCT present in 50% of cases endometrial hyperplasia due to the high levels of estrogens, therefore transvaginal ultrasound examination is recommended to assess the endometrial thickness and decide if endometrial biopsy is necessary ,21. EndoAn early diagnosis means a quicker treatment and, therefore, a better prognosis and the possibility of preserving fertility, especially for young patients with GCT .In patients of reproductive age, when fertility preservation is desired, for early FIGO stages (IA) GCT, unilateral oophorectomy with multiple peritoneal biopsies, and washing cytology is acceptable. The complete surgical treatment is postponed after childbearing and completion of family planning ,21. In SGranulosa cell tumors are hormonally active tumors, causing transient infertility as shown in our case. An associated risk factor for infertility was the proximal obstruction of the left tube while the right tube was normal with positive methylene-blue test during laparoscopy . 3 volume, during the infertility investigations in a patient with secondary amenorrhea. This anechoic mass of only 3 cm diameter could have been misdiagnosed even with a luteum corpus due to the increased peripheral vascularity.Currently there are no imaging criteria for the diagnostic of GCTs due to the rarity of these tumors . MoreoveGranulosa cell tumor of the ovary has a favorable prognosis and for patients of reproductive age fertility preservation is crucial. In order to establish imaging criteria for the diagnosis of GCTs, further research is needed.In summary, endocrine disorders need the evaluation of inhibin B levels even if the ovaries appear normal on ultrasound examination, aiming not to omit an occult ovarian tumor. Elevated inhibin may be sign of the presence of an unsuspected tumor.


The transient occlusion of the terminal thoracic duct is a rare disease responsible for renitent supraclavicular cysts. The aim of this study was to describe the clinical characteristics, evolution, and treatment.A retrospective multicenter study and literature review was carried out. The literature search (PubMed) was conducted including data up to 31 December 2020 and PRISMA guidelines were respected.This study identified 6 observational cases between September 2010 and December 2020. The search results indicated a total of 24 articles of which 19 were excluded due to the lack of recurrent swelling or the unavailability of full texts (n = 5). Fourteen patients (8 from literature) mostly reported a noninflammatory, painless renitent mass in the supraclavicular fossa which appeared rapidly over a few hours and disappeared spontaneously over an average of 8 days (range: from about 2 hours to 10 days). Anamnesis indicated a high-fat intake during the preceding days in all cases and 7 from literature found in the Medline databases. Recurrences were noted in 10 patients. Thoracic duct imaging was performed in all cases to detect abnormalities or extrinsic compression as well as to eliminate differential diagnoses.A painless, fluctuating, noninflammatory, and recurrent swelling of the left supraclavicular fossa in patients evoking an intermittent obstruction of the terminal portion of the thoracic duct was identified. A low-fat diet was found as safe and effective treatment. The thoracic duct extends superiorly in the posterior mediastinum to collect thoracic lymph via posterior intercostal channels to empty into the junction of the left subclavian and jugular veins.,3 The pathogenesis of these cysts includes congenital weakness in the duct wall, an acquired inflammatory process, as well as the postoperative or traumatic disruption of lymphatic drainage. When supraclavicular cysts are persistent, patients are most often referred to a surgeon who will discuss surgical intervention which most often results in thoracic duct ligation and includes lymphovenous anastomosis.–9 Less frequently, paroxysmal cysts of the terminal part of the duct appear as a renitent mass above the left clavicle.–12 Diagnosis can be difficult in these cases and physical examinations or imaging might be performed after the mass has disappeared. The aim of this study was to describe and review cases of recurrent lymphangiectasia of the left supraclavicular fossa. The epidemiological, clinical, evolutionary, and therapeutic aspects of this rare occurrence were also analyzed. Cases were collected according to 2 methods. The first was a case collection from memory from the centers of Lyon, Clermont-Ferrand, and Le-Puy-En-Velay from September 2010 to October 2020. The second was completed with a systematic review of the literature.Even though it is rare, lymphoceles or cysts on the terminal part of the duct can develop and become permanent supraclavicular masses.2The Departments of Internal Medicine at Le-Puy-En-Velay, Lyon, and Clermont-Ferrand were first contacted to collect memory observational cases of recurrent thoracic duct cyst of the left supraclavicular fossa. This initial process resulted in 6 observations from September 2010 to December 2020. Information on the study and its written consent was sent to all patients involved. Institutional review board of the hospital of Le-Puy-En-Velay approved the study. The search parameters were limited to Medline databases which included PubMed and the National Library of Medicine in Bethesda, MD. Publication titles and abstracts were initially screened followed by a reading of the full applicable texts. Original papers published in English or French were eligible for inclusion.The literature review was based on a search for articles concerning intermittent terminal thoracic duct cysts that were published before December 31, 2020 and performed according to the PRISMA guidelines.The following PubMed search strategy was used: ((thoracic duct [MeSH Terms]) AND (cyst [MeSH Terms])) OR (lymphangiectasia [MeSH Terms]). All articles were selected without time restrictions. Reference lists of articles were scanned for references not initially identified in the primary search. No exclusions for study type, sample size, or setting were applied. The extracted variables consisted of the type of study, age, gender distribution, disease duration, recurrences (both in number and frequency), complications, triggering factors, treatment, and the duration of follow-up. Studies fulfilling these inclusion criteria were reviewed by all authors.All titles that were irrelevant to this study were excluded during the first identification phase. Only articles that contained clinical data about recurrent thoracic duct cysts around the left supraclavicular fossa were retained. Abdominal or intestinal cysts, as well as permanent supraclavicular thoracic duct cysts were rejected. Studies containing only therapeutic or radiological data were not considered for the following case descriptions. Risk of biases was not evaluated because of all the studies were case reports.https://www.crd.york.ac.uk/prospero/, (number CRD42021246163) and the protocol was not prepared. Authors declare no conflict of interest.The study was registered on 3Six observational cases were identified by contacting the internal medicine departments of 3 hospitals in southeastern France  from September 2010 to December 2020. The following are descriptions of these original series (n = 6) of observational cases 1 to 6.3.1A 50-year-old man with a medical history of surgery for an inguinal hernia was urgently admitted for a left supraclavicular swelling which appeared when he woke up the same morning. He was not taking any medication and there was no history of occupational exposure. The mass was neither painful nor inflamed and subsequent laboratory tests were clear. A computed tomography (CT)-scan showed an infiltration of the soft tissue located on the left side of the neck and in the posterior mediastinum. The left internal jugular vein appeared tubular which suggested thoracic duct thrombosis. There was also an upstream expansion associated with a minor pleurisy on the left side Fig. . A Doppl3.2A 74-year-old woman was admitted to the hospital because of a sudden swelling of the left supraclavicular fossa. She had a history of high blood pressure and hypothyroidism due to a partial thyroidectomy. She had taken L-thyroxin and an angiotensin-converting enzyme inhibitor. One year prior, she suffered from a similar episode which resolved itself within a few days without treatment. A high-fat meal and alcohol intake preceded both of these events. Laboratory tests were normal, however, a CT-scan showed a minor bilateral pleural effusion (predominant on the left side), an infiltration of the left side of the neck expanding to the left hollow armpit and the mediastinum, several supraclavicular adenomegalies, and an unraveled appearance of the left internal jugular vein which was deemed congruent with a possible thrombosis. An anticoagulant therapy was therefore started. Doppler ultrasound was performed 72 hours after admission and did not reveal any thrombosis and treatment was discontinued. The patient's outcome was spontaneously favorable in 24 to 48 hours and a CT-scan was subsequently performed later which came back normal.3.3A 45-year-old woman was seen in the internal medicine unit complaining of pain in the left supraclavicular fossa. She had a history of right shoulder surgery for calcifying tendinopathy following corticoid infiltration and she complained of headaches. She was using a copper intrauterine device but was not taking any medication. For a few months, she experienced night sweats without any weight loss and for 1 month, she suffered from a painful swelling of her left supraclavicular fossa as well as difficulties in swallowing. Fifteen days after the onset of these symptoms, she had a fever lasting 24 hours. Ultrasonography was performed which showed inflamed and infiltrated subcutaneous tissue on the supraclavicular fossa and on the omohyoid muscle. A CT-scan confirmed the findings and also indicated an extended inflammatory infiltrate in the retroperitoneum. Laboratory tests were normal. During examination, the patient was in good general condition; however, there was a swollen and painful mass on her left supraclavicular fossa. During an abdominal examination, there was pain in the right hypochondrium and iliac fossa. The outcome was spontaneously favorable within 48 to 72 hours. A magnetic resonance imaging (MRI) scan of the thoracic duct showed a small cyst on the cervical portion. After 3 years of follow-up, no recurrence occurred.3.4 on both sides with the left side impregnation being the slowest. There was also a 14 mm adenopathy. Simple monitoring was proposed.A 65-year-old woman was seen in the internal medicine unit for an intermittent swelling of her left supraclavicular fossa located on a preexisting area of chronic infiltrations Fig. . Her med3.5A 64-year-old woman was referred for an internal medicine consultation for reoccurrence of diffuse abdominal pain associated with a left supraclavicular edema  with recurrent duct cysts of the left supraclavicular fossa. The first case had recurrent swelling for 3 months and the diagnostic was established by echography, MRI and surgery (lymphatic fluid in the cyst). The second case patient had a recurrent mass in the left supraclavicular fossa for 7 months corresponding to a duct cyst after being detected with an echography, RMI, and surgery. The third case had swelling in the left supraclavicular fossa for 10 years. Diagnosis of the duct cyst was made by echography, tomodensitometry, and surgery. The last case consulted for a mass in the left supraclavicular fossa for several weeks. Echography, tomodensitometry, and surgery made the diagnostic of these recurrent thoracic duct cysts. All 4 patients did not have a significant medical history and took estrogen-containing medication at the onset of neck mass enlargement. Surgery was performed because the cyst was cosmetically disturbing (mass were noninflammatory). Recurrence after surgery only appeared in the fourth case.4.Zatterstrom et al reported the follow-up of a 55-year-old man who was consulted 25 years ago for a fluctuant supraclavicular mass that appeared a few months before. The diagnosis was established by tomodensitometry, fluid puncture, and pedal lymphography. No treatment was made. Nine years after, there was a progression of the cyst, followed by the cyst diminishing spontaneously 13 years later and disappearing 25 years after. Retrospectively, it was reported that a high fat diet triggered the swelling.5.Van Den Bussche et al described the case of a patient with swelling on the left side of the neck spontaneously appear . This patient was an 83-year-old woman. Echography, tomodensitometry, and puncture confirmed duct cyst. Moreover, the cyst was punctured and was kept on a medium chain triglyceride diet. No recurrence appeared at the follow-up (1 month later). The authors of the 4 articles were mostly surgeons,9,15,16 and the remaining article was written by a radiologist.The data from 8 external cases along with cases from our institutions are shown in Table Studied patients were predominately female  with only 1 case from the literature search described as a male and 1 man was included in our case reports. The mean age of patients included in this study was 51 years old  and there was no difference between our data and the literature found on Medline. All patients presented a painless mass of the left supraclavicular fossa. The mass was always noninflammatory, renitent, transient, nonpulsatile, and compressible. Palpation of the mass was painless and compressible. Clinical examinations between relapses were strictly normal. The mean duration of the episodes was 8.4 days and ranged from a few hours to 1 month with a median of 9 days . The evolution duration of the mass could only be included in 9 cases because Preyer et al did not specify this data, and Zatterström described a fluctuating mass  that had existed for 25 years and had grown constantly until a change in diet made it disappear.,16Two cases were associated with ascites and pleuritis.3.8 Two other cases showed a high-fat diet was consumed a few days before the episodes. Zatterström et al described the disappearance of the supraclavicular mass after the patient initiated a change in diet. In the cases handled by the authors of this study, a high-fat diet has been clearly identified in 4 cases and was strongly suspected in the 2 other cases since dietary intervention made it possible to resolve the symptoms.A triggering factor was identified in 12 of the 14 cases. Preyer et al assumed the intermittent obstruction of the terminal portion of the thoracic duct was due to an estrogen pill, but the article did not specify data related to the patient's diet prior to the appearance of the swelling.3.9,12 Tomodensitometry showed an inconsistent cystic mass in the left supraclavicular region combined with an infiltration of the soft tissue in the left side of the neck.,16 Tomodensitometry could also have shown pleural effusion or ascites. All subsequent examinations were normal following the acute phase. Laboratory tests were deemed normal and a lack of any inflammatory syndrome was evident.All patients underwent an ultrasound. Tomodensitometry was used in 13 cases, with an MRI in 3, and positron emission tomography scan was done for 1 case. Lymphoscintigraphy was performed in 4 cases and showed an increased delay of impregnation on the axillary lymphatic vessel. During the acute phase, ultrasound imaging showed infiltrated subcutaneous tissue with a hypoechoic mass with liquid in the left supraclavicular fossa in some cases.,9,12 a puncture of the mass was performed but none were done in any of the cases in our study. In 4 cases, no puncturing occurred because ablation was directly performed. In the observational study case of the supraclavicular mass, which was associated with pleuritis, Veziant et al completed pleural puncturing because it was more easily carried out than a puncture procedure. When punctures of mass or pleura were accomplished, a milky fluid that contained numerous lymphocytes , low albumin level , high triglycerides levels , and no abnormal cells,9,12 was found in all subjects. The biochemical analyses of this liquid were in favor of chyle.In 3 cases found in the literature search,3.10 Van den Bussche et al described a case without reoccurrence and the follow-up lasted only 1 month.The duration of patient follow-up beginning with the detection of the renitent mass to diagnosis varied greatly with a mean duration of 4.7 years . Follow-up after therapeutic intervention depended on the proposed and short follow-ups were justified because 4 patients had undergone surgery quickly after diagnosis.3.11 Eight cases received a low-fat diet alone including 2 cases of literature,,15 In 1 case a no-fat diet was proposed first and surgery was done after the first recurrence 10 years later. In 1 case, patient had a low-fat diet associated with a mass puncture without recurrence but the follow-up was short (1 month). In our subjects, dietary intervention was the only treatment and all the patients were advised on dietary rules with 2 benefiting from a strict diet of light-chain triglyceride removal. No complication was described in the case of low-fat diet. Preyer et al reported a surgical complication related to a chylous fistula.In 4 cases surgery was performed quickly after diagnosis.4This study comprised the largest set of patients with recurrent lymphangiectasia of the left supraclavicular fossa. This disorder mostly affects middle-aged women and appears as a left supraclavicular mass which is neither inflammatory nor renitent. It is transient and regresses in an average of 8 days. A recent high-fat diet is a major triggering factor. In the acute phase, lymphoscintigraphy remains the benchmark because it can reveal thoracic duct obstruction; however, this procedure is increasingly being replaced by noninvasive tests. Imaging should be repeated after the acute episode to eliminate differential diagnoses. A low-fat diet is frequently proposed and it is most often effective in preventing recurrences.–8,17–19 sequelae of a prior injury ,,15,18 lymphangioma,17,19 or hematoma. In these cases, a clinical examination and medical imaging during the acute phase should guide a clinician. The most plausible explanations for this disorder are a weakness of the thoracic duct wall.,4,16 This weakness can be congenital, related to an inflammatory process, or stem from an anatomical conflict at the angle between the left intern jugular vein and the left subclavicular vein.Overall, despite some differences regarding clinical and imaging features, the stereotypical clinical history in all cases suggests the same disease. No large-scale studies describing clinical, imaging, prognosis, or treatment parameters were found in this study. Moreover, this disease has probably been underestimated and underdiagnosed since only 6 observed cases at 3 internal medicine departments were found over a 10-year period in the medical facilities. It should, however, remain a diagnosis of exclusion and it may be therefore crucial to exclude differential diagnoses such as a tumor-like metastatic lesions, a parathyroid or thymic cyst,,16,17,20 It is important to note that the cases involved combined oral contraceptive use dated from 1995 which was at a time when the average dosage of estrogen was high. A high-fat diet can be a triggering factor because it increases pressure in the thoracic duct canal with the resulting production of chyle that is composed mainly of lymphocytes and lipid-rich fats. The designation “Nutella Syndrome” that was found in 1 publication has sometimes been used because of the link between recurrences after consumption of a high-fat meal and we propose to name it.In most of our patients, triggering factors were a high-fat diet and combined oral contraceptive use.,10 Doppler ultrasonography should be carried out first in the case of swelling of the supraclavicular fossa since it is noninvasive and can be performed quickly.,20 It may show a cystic lesion, hypoechogenic to echofree mass, with no connections to vessels, sono compressible, sharply outlined, with no internal perfusion.,10,12,18 In the acute phase, tomodensitometry can show a dilation of the thoracic duct or cysts located adjacent to the left internal jugular vein.,18 Cervical soft tissue surrounding the cyst can appear infiltrated with edematous fluid. The mass is hypoechoic, homogenous, thin-walled, and emit water attenuation signal inside.–7Thoracic duct imaging is decisive because it reveals secondary causes of dilatation and/or malformation such as lymphangioma, stenosis of the terminal valve of the thoracic duct, extrinsic compression, and venous thrombosis, all of which require specific treatment plans.,18 sometimes with dilated a thoracic duct and apparent communication of the cyst with the thoracic duct.,7 Repeating radiological examinations after the acute phase is important because an edema present in the initial phase may mask abnormalities of the terminal portion of the thoracic canal.,9 In the case of the “Nutella Syndrome,” imaging taken after the acute crisis must be normal. Lymphoscintigraphy is the benchmark because it provides a proper analysis of the shape of the thoracic duct and can measure its drainage rate.,14,19,21 Today, CT-scans and MRIs are more commonly used.An MRI can highlight bright lesions on the T1 and T2-weighted imaging results arising from the thoracic duct close to the left subclavian vessels,,21 since normal diffusion time values are from 10 to 30 minutes and considered delayed after 120 minutes. In case of dilation of the thoracic duct, it increased delay of diffusion up to the thoracic duct, without extravasation.,15,18Lymphoscintigraphy is time-consuming, invasive, and can be difficult to interpret in the absence of standardized procedures,17 When the cyst is removed, immunohistochemical analysis can show CD31 CD34 factor VIII and keratin positivity which are biomarkers of the epithelial and endothelial nature of a wall vessel, thus removing any doubt about cancer or a lymphocele.,12,15,22 Complications can occur when cysts become permanent and cause compression of the surrounding anatomical structures.,9,10In doubt of diagnosis, a puncture to the cyst can be performed to indicate a chyle-like liquid composed of 90% to 100% lymphocytes and rich in triglycerides.,17,23 because medium-chain triglycerides are directly absorbed into the portal system.,23 In our study, a dietary regime with or without total exclusion of long-chain triglyceride was offered systematically as a first step because it is safe and usually enough to control the disease. Surgical intervention is rarely considered and should be reserved for highly symptomatic and serious cases.Therapeutic treatment management is not well defined and should be guided by the patient's symptoms. According to the symptomatology, a restricted diet should be discussed first. The diet should exclude food rich in fat. If long-chain triglycerides are completely excluded from the diet, medium-chain triglyceride supplementation should be introducedOur study had several strengths. To our knowledge, it is the first literature review conducted on this disease. Of the 14 described cases, we reported 6 which had follow-ups on clinical outcomes allowing a better description of the pathology. Limitations were related to the retrospective nature of the study and lack of subsequent data. A potential recall bias may have occurred because some observations were solely based on 1 doctor's remembrance. As previously discussed, this disease is rare and potentially underdiagnosed. The prevalence of this disease is still unknown and other studies are required to determine its overall prevalence, clinical presentation, evolution, and pathophysiology with more accuracy.5An intermittent swelling of the left supraclavicular fossa should raise suspicion that an intermittent cyst may be in the terminal portion of the thoracic duct. It is important to look for any unusual intake of high-fat foods preceding symptoms. Thoracic duct imaging is crucial to eliminate differential diagnoses. Lymphography remains the benchmark for diagnosis, however, noninvasive imaging technics (MRI or CT-scan) are currently preferred. In most cases, therapeutic management is a conservative way to manage this disease with dietary intervention consisting of a low-fat diet.Conceptualization: Julie Planchette, Benjamin Castagne, Anne-Sophie Resseguier, Pascal Seve.Investigation: Julie Planchette, Clara Jaccard, Audrey Nigron, Jean-Baptiste Chadeyras, Guillaume Le Guenno, Benjamin Castagne, Anne-Sophie Resseguier, Pascal Seve.Methodology: Julie Planchette.Supervision: Yvan Jamilloux, Pascal Seve.Writing – review & editing: Yvan Jamilloux, Pascal Seve.


Synchronous malignancies of gallbladder and biliary tree are together rare entity whose pathogenesis is yet unknown. We report the case of a triple synchronous cancer of 3 distinct location: gallbladder, common bile duct (CBD) and papilla of Vater.An 84-years-old woman, was admitted to our Hospital with clinics features of obstructive jaundice.Dilatation of the biliary tree and CBD without evidence of gallstones was seen at US. CT scan confirmed distal CBD obstruction.endo-US showed a nodule of the head of pancreas infiltrating the lower CBD.An Finally, hepatic-MRI displayed a gallbladder malignancy with invasion of CBD.endo-US and malignancy of gallbladder on MRI.Preoperative staging showed 3 diagnostic suspicions: carcinoma of CBD on CT, pancreatic carcinoma on A cephalic duodenopancreatectomy and radical gallbladder resection was performed.Final pathology revealed 3 distinct location of moderately differentiated adenocarcinomas: Gallbladder, CBD and Vater's papilla.Microscopic examination didn't detect any direct continuity between the 3 tumors. Metastases were identified in the pancreaticoduodenal, peri-hepatic and peri-gastric lymph nodes.Literature displayed 22 cases of synchronous malignancies of gallbladder and CBD and 1 case of triple cancer with associated Vater's papilla carcinoma.In most of these cases, an association with an anomalous pancreatic-bile duct junction was reported.Although the real incidence remain unknown, it was reported to occur in 5–10% of CBD cancers.Suspicion of such combination of cancer should be remembered, especially when preoperative investigations don't allow a precise localization of tumor in the biliary tree. •Rare case report of biliary tract cancer•Diagnosis and treatment of multiple biliary tumors•Differential diagnosis of biliary tract tumors Recent studies, mainly from Japanese authors, have shown that these lesions are usually associated with an anomalous pancreatic-bile duct junction (APBDJ) It is also important to distinguish between synchronous malignancies with local metastasis from a primary cancer in the billiard tree. Warren et al. We report the case of a triple synchronous cancer of the gallbladder, common bile duct and papilla of Vater, the diagnostic path and surgical management.This case report has been reported in line with the SCARE Criteria [include citation]' at the end of the introductory section 2An 84-years-old Caucasian woman, known for hypertension, chronic renal failure and antecedent of hysterectomy, was admitted to our Universitary Hospital with abdominal pain and jaundice developing since a few days. The patient is in good general condition, independent, lives alone at home and does not report significant weight loss in the last period. No family history reported for other hepatobiliary and pancreatic tumors. On admission, blood samples showed an important cholestasis with a serum total bilirubin level of 222 micmol/l and serum direct bilirubin level of 190 micmol/l. Abdominal ultrasonography revealed dilatation of the intrahepatic biliary tree and of common bile duct (CBD), without evidence of gallstones in the gallbladder.Because of an acute renal failure due to hyperbilirubinemy, a non-contrast-enhanced CT scan was performed. This exam confirms an irregular dilatation of intrahepatic biliary tree with an obstruction in the distal part of common bile duct associated with pathologic local lymph nodes and a suspect lesion of segment IVb of the liver .Fig. 1CTTo avoid cholangitis, the patient rapidly underwent an endoscopic retrograde cholangiopancreatography (ERCP) with drainage of the lower CBD by a plastic stent. An endoscopic ultrasound (EUS) was performed at the same time, showing a nodule of the lower CBD infiltrating the head of pancreas and a biopsy of it was made .Fig. 2EnThe latter showed a well-differentiated adenocarcinoma. We completed the pre-operative staging with a hepatic magnetic resonance that showed also a suspected malignancy of gallbladder with invasion of cystic duct and CBD .Fig. 3MRTumor marker CEA was 4.5 μg/l and CA 19.9106 KU/l.Facing three different diagnostic suspicions after radiological and endoscopic investigations , we decided to perform an explorative laparoscopy with wedge resection of IVb liver nodule showed in the MRI. No carcinosis neither malignancy were found at abdominal exploration and final pathology of the specimen respectively.After multidisciplinary discussion and considering patient's will, the surgical approach was decided.The patient underwent a Whipple's cephalic duodenopancreatectomy, associated with a radical excision of gallbladder with hepatic resection of IVb and V segment, due to intraoperative suspicion of gallbladder cancer involving the CBD . The intFinal pathology report revealed the presence of three distinct cancers, respectively: moderated differentiated adenocarcinoma of gallbladder  with invImmunohistochimical analysis showed defects in DNA mismatch repair (MMR) MLH1 and PMS-2 proteins, involved in the induction of p53 and apoptosis.The pathological final staging was: pT3 pN1 L1 V1 Pn1 G2 R0 for the gallbladder adenocarcinoma; pT3 pN2 L1 V1 Pn1 G2 R0 for the CBD adenocarcinoma and pT2 pN2 L1 V0 Pn0 G2 R0 for the Vater's papilla adenocarcinoma.The postoperative course was long, with a slow recovery by the patient. No significant complications were found.After multidisciplinary discussion, in consideration of the general condition of the patient and the long postoperative recovery, it was decided for a clinical and instrumental follow-up.3Synchronous malignancies of the gallbladder and biliary tree are rare. However, there are increasing reports, mainly from Asiatic authors, suggesting that this condition is not as rare as early reported, with an incidence of approximately 5–7.4% The pathogenesis of synchronous malignancies of gallbladder and extra-hepatic bile duct is yet unknown It is also important to distinct synchronous primary malignancies to metastasis from a primary elsewhere in the biliary tree. Warren et al. The distinction between metastasis and synchronous primary is an important prognostic factor in simultaneous lesions. In fact a better prognosis has been reported for synchronous primary lesions, if a complete R0 surgical resection is possible 4Synchronous malignancies of gallbladder and biliary tree are rare conditions, but according to a more attentive surgical and pathological examination are now more common. Therefore it is important to keep a high index of suspicion, mostly when preoperative investigation don't allow a precise localization of the tumor in the biliary tree. When synchronous lesions are identified, looking for an anomalous pancreatic-bile duct junction as a possible cause and distinguishing primary lesions from metastasis, It's mandatory in order to correctly estimate the patient's prognosis.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.None.Patient consent.Stefano PassoniStefano Passoni writing the paper, Takamune Yamaguchy revision literature.Emilie Uldry revision literature, Emmanuel Melloul revision literature, Nermin Halkic writing the paper, Alessandra Cristaudi writing the paper.None.


Klebsiella pneumoniae. The patient was managed successfully with ultrasound-guided percutaneous aspiration and insertion of a drain along with antibiotics and supportive measures, and no laparotomy was performed.Acute abdominal pain with free air under the diaphragm visible on chest/abdomen X-ray (pneumoperitoneum) is a medical emergency. Most of such cases of pneumoperitoneum are attributable to perforated hollow viscus; however, other possibilities like rupture of liver abscess (by a gas-forming organism) also need to be considered. Further imaging like a CT scan might help in the diagnosis and would also obviate the need for laparotomy in some of such cases. We report a case of acute abdominal pain with gas under the diaphragm due to a ruptured liver abscess caused by  Klebsiella pneumoniae.Acute abdominal pain with gas under the diaphragm is a medical emergency, and the most common cause is the perforation of a hollow viscus that constitutes about 90% of the cases . Other c2: 99% breathing on room air. Abdominal examination revealed tenderness over the epigastric area and right hypochondrium. There was no evidence of free fluid in the abdomen. A review of other systems was unremarkable.A 58-year-old gentleman of southeast Asian origin was admitted with complaints of generalized tiredness and fatigability for two weeks, and epigastric and right shoulder pain for the one-week duration. He denied fever, change in bowel habits, or respiratory complaints. His past medical history includes hypertension and Type 2 diabetes mellitus. Vital signs on admission were temperature: 36.7°C, pulse rate: 112/minute, blood pressure (BP): 123/71 mmHg, respiratory rate: 18/ minute, SpOInitial investigations showed neutrophilic leukocytosis with elevated inflammatory markers. The metabolic profile revealed elevated blood urea with normal creatinine, hyponatremia, and deranged liver function test. Random blood glucose showed severe hyperglycemia 43.1 mmol/L) and raised serum beta-hydroxybutyrate (1.6 mmol/L). A blood gas study showed a normal pH and bicarbonate. Serum lactate level was mildly elevated  and metronidazole were initiated. Hyperglycemia was managed with insulin and intravenous fluids. An urgent computerized tomography scan (CT scan) of the abdomen with contrast was performed, which showed a large right subcapsular hepatic lesion of 11.5 cm x 8.5 cm x 9 cm size with an irregular outline, predominantly containing gas with dependent fluid suggestive of gas-forming hepatic abscess. There was a possibility of rupture, with an associated pneumoperitoneum in the form of free air in the right subphrenic region along with the anterior and inferior surface of the liver Figures -4..Under ultrasound guidance, aspiration of the abscess was done, and 125 ml of pus was drained Figures .Klebsiella pneumoniae, and the antibiotic was changed to ampicillin/sulbactam based on the sensitivity result. The pain and laboratory markers started showing improvement following drainage and antibiotics. However, on the fifth day of admission, he again complained of pain over the right shoulder and right upper abdomen. Repeat ultrasound of the abdomen revealed re-demonstration of previously seen liver abscess with large volume, about 590 mL  was inserted into the abscess. 650 mL pus mixed with blood was drained over the next 24 hours. His clinical condition showed significant improvement with concomitant improvement in inflammatory markers. The antibiotic was de-escalated to intravenous ceftriaxone. Repeat ultrasound abdomen was performed (on day 30), which showed a small amount of residual organized phlegmon, unsuitable for aspiration. As the draining ceased, the catheter was removed, and the patient was discharged with a plan to continue antibiotic for a total of six weeks. On follow-up after four weeks, the patient was doing fine, and the repeat ultrasound was unremarkable.Acute abdominal pain with gas under the diaphragm (pneumoperitoneum) is a medical emergency requiring urgent evaluation and management. In pneumoperitoneum, there is free air in the peritoneal cavity. It is diagnosed by an erect X-ray of the chest or abdomen. The most common cause is perforated hollow viscus , constituting around 90% of the cases . The othKlebsiella pneumoniae. In a study from Taiwan enrolling 22 cases of GFPLA, K. pneumoniae bacteremia was noted in 17 patients (77%) [Escherichia coli (E. coli), Pseudomonas, Salmonella spp, and Clostridium spp. Salmonella is a rare pathogen for GFPLA [Klebsiella pneumoniae was grown in blood and pus culture.Rupture of liver abscess induced by a gas-forming organism is one of the rare causes of pneumoperitoneum. Gas forming pyogenic liver abscess (GFPLA), also known as emphysematous liver abscess, has the highest incidence in Southeast Asia, especially Taiwan . It has or GFPLA . In the Gas forming liver abscess has been more common in diabetic patients than non-diabetic patients . MoreoveKlebsiella pneumoniae found that nitrogen was the predominant gas detected in all the samples. The other gases were carbon dioxide, hydrogen, and oxygen [Gas associated with infection usually consists of nitrogen and carbon dioxide released via glucose fermentation by gas-forming bacteria. These bacteria derive their energy mainly from glucose by fermentation through various pathways, and mixed acid fermentation is the most preferred pathway . The hypd oxygen . GFPLA diagnosis is usually made by radiological images demonstrating gas in the liver parenchyma. Plain (erect) abdominal radiographs show abnormal gas patterns, air-fluid levels and mottled gas patterns being the most common findings, but the plain radiographs are less reliable. Gas formation in the liver parenchyma is noted in only up to 36% of patients with GFPLA on plain radiograph films . Free aiIn our patient, the plain film revealed right subdiaphragmatic free air suggesting pneumoperitoneum with heterogeneous liver shade and gas-fluid level. CT scan confirmed features suggesting gas-forming hepatic abscess and pneumoperitoneum.Treatment of GFPLA includes appropriate antibiotic cover, adequate drainage to improve the tissue perfusion to facilitate gas transport, and good control of blood sugar. GFPLA has been traditionally managed by surgical exploration and drainage. The last few decades witnessed a marked shift from the traditional surgical exploration and drainage practice to image-guided percutaneous transhepatic drainage. A study examining 22 cases of emphysematous liver abscess reported percutaneous transhepatic abscess drainage in 19 patients and surgery in one case . DrainagIn our patient, though it was a ruptured GFPLA, instead of doing surgical drainage, the surgical team and the interventional radiologist opted for percutaneous drainage under ultrasound guidance, followed by deployment of catheter drain, and the patient improved without requiring open surgery.Most of the cases of acute abdominal pain with pneumoperitoneum are attributable to perforated hollow viscus. However, other possibilities like rupture of liver abscess (by the gas-forming organism) also need to be considered. Further imaging like a CT scan might help diagnose and obviate the need for laparotomy in some cases. Our patient was successfully managed with ultrasound-guided percutaneous aspiration, drain insertion, and antibiotics, along with supportive measures.