Intramuscular myxomas are rare, benign mesenchymal tumors in the musculoskeletal system, and usually, the tumors arise in the large muscles of the thigh, buttocks, shoulder, and upper arm. However, a tumor of the forearm is very rare. Herein, we describe the case of an intramuscular myxoma in the supinator muscle of a 56-year-old female patient.Magnetic resonance imaging showed a well-defined mass that was hypointense with the peritumoral fat ring sign. The differential diagnoses might have been myxoma, schwannoma, or intramuscular hemangioma. The histopathological image showed abundant myxoid tissue, hypocellularity, and poor vascularization. The cells of the tumor were spindle and stellate-shaped with normochromic nuclei. Based on these findings, the pathological diagnosis was an intramuscular myxoma. After excising the tumor, the patient had transient posterior interosseous nerve palsy.This tumor is curative by resection in toto; however, when the tumor exists in the forearm, surgeons should be careful to avoid damaging surrounding tissues because the tumor is very hard and relatively large compared to the forearm. They have an incidence of 0.1 to 0.13 per 100 000 persons . Intramu2A 56-year-old female patient was referred to our hospital for a mass lesion in her forearm that had been growing slowly, and she had no history of trauma, infection, fever, or weight loss. During medical history taking, we found that a needle biopsy was performed 4 years ago in another hospital, and the result of the cytology examination was class II. The patient also complained of extension lag of the metacarpophalangeal joint of the middle finger that had gradually proceeded without sensory loss. The physical examination revealed an ill-defined area of swelling at the middle part of the forearm. The palpable mass was swollen, measured about 30×30 mm, was smooth and fixed without tenderness or the Tinel’s sign, and had very hard elasticity.1), and a hyperintense area was shown on T2-weighted images (T2WI) . Intravenous Gadopentetate Dimeglumide of Gadolinium (GDG) enhancement revealed peripheral enhancement of the mass with linear stranding inside the tumor . The imaging findings characterized the mass as intermuscular myxoma; the differential diagnosis might have been myxoma, schwannoma, or intramuscular hemangioma.The patient was evaluated with radiography, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI). On the x-ray, there was no scalloping, osteolysis, pathological fracture of the radius or ulna, or calcification of soft tissue. On the CT scan, the mass had a low density within the right supinator muscle. The MRI scan of the right forearm revealed a 37×22×27-mm well-defined mass that was hypointense; additionally, the peritumoral fat ring sign was indicated on T1-Weighted Images (T1WI) . Mitotic activity, necrosis, and nuclear atipias were not seen. Based on these findings, the pathological diagnosis was an intramuscular myxoma.During the histological examination, a cut section of the mass showed glossy grey-white glistening gelatinous areas macroscopically. Microscopy showed that the cells were spindle and stellate-shaped, and collagen fiber was in abundance in the mucoid hypocellular material of neoplasms with low vascularity (Fig. Postoperatively, there was no problem during the process of wound healing. However, she had difficulty extending the metacarpophalangeal joint of the right fingers without sensory disturbance. The Manual Muscle Testing System  showed tShe did not undergo an electrophysiological examination; however, on the basis of findings from physical examinations, we made a diagnosis of posterior interosseous nerve palsy due to compression during the operation. We prescribed an orthosis for functional recovery of her fingers. Three months postoperatively, the posterior interosseous nerve palsy improved completely. She has not shown any signs of recurrence detected by MRI 1 year later.3Myxomas are benign connective tissue tumors from stellate mesenchymal cells that lose their capacity to produce collagen, and they occur at various locations, such as the heart and bones . In 1948Intramuscular myxomas usually have a cystic-like appearance on a radiograph, homogeneous low-density lesion appearance on a CT scan, hypointense appearance on T1WI, and hyperintense appearance on T2WI. Fat or edema in the surrounding muscles, the so-called peritumoral fat ring sign, on T1WI and increased signal in the adjacent muscle on T2WI are diagnostic signs for distinguishing intramuscular myxomas from other myxoid tumors. Additionally, GDG may show peripheral and internal enhancement . In the Intramuscular myxomas are usually treated with local surgical excision, and recurrences are very rare. Surgeons have to remove the tumors with a clear margin because local recurrences result from incomplete resection. Our patient had no symptoms of recurrence clinically and radiographically 1 year after resection.There is only one report of a myxoma in the supinator muscle; the patient had posterior interosseous nerve palsy before surgical resection . In our We described the rare case of an intramuscular myxoma in the supinator muscle. The tumor is curative by resection in toto; however, when the tumor exists in the forearm, surgeons should be careful to avoid damaging surrounding tissues.


We describe a case in which retained wires from a continuous glucose monitor were removed from the abdominal wall and peritoneum of a 6‐year‐old boy. We highlight a concern for continuous glucose monitor use in children and discuss surgical techniques used to retrieve tiny, mobile objects from complex body cavities. Retained foreign bodies are frequently discovered incidentally, and asymptomatic foreign bodies can oftentimes be managed nonoperatively. However, certain foreign bodies have the potential to migrate, and may injure tissues and organs, prompting immediate surgical retrieval.Continuous glucose monitors (CGMs) are increasingly popular devices for patients with type 1 diabetes mellitus. A hair‐thin wire is introduced over a needle subcutaneously, usually into the abdominal wall, to facilitate real‐time reading of glucose levels from the interstitial fluids in the subcutaneous tissue as a proxy for blood glucose. The accidental introduction of this sensor wire into the peritoneal cavity is a theoretical risk of this technology.We present the case of a child with two retained wires from a CGM system, including one unexpectedly trapped inside the peritoneal cavity, to highlight this rare problem and illustrate intraoperative strategies for finding and extracting such a small, mobile object.2The patient is a lean 6‐year‐old boy with a history of celiac disease who was diagnosed with type 1 diabetes mellitus and started on a continuous glucose monitor. Five months later, his parents placed a new sensor in the right lower quadrant abdominal wall. They did not receive a signal from the sensor and removed it, but noticed the wire had detached. By the following week, pain, swelling, and redness were noted over the site. An X‐ray revealed the retained wire within the abdominal wall at the insertion site. An elective removal of the wire under sedation was scheduled with pediatric surgery. Prior to removal, the parents reported placing another sensor from the same box into the abdominal wall in the left lower quadrant. Once again, they did not receive a signal from the sensor, removed it, and found that the wire had detached. Another X‐ray was obtained which showed a foreign body on the right side, corresponding to the first lost wire  needle detachment from steel insulin infusion sets, removed uneventfully under fluoroscopy.In our case, the intraperitoneal wire retrieval was challenging for several reasons. First, the size of the target object was subcentimeter and very thin. In addition, the object migrated continuously during our search, as we grasped or retracted different tissues without knowing the exact location of the target. Finally, the operative field  was complex and heterogeneous. We began by directly inspecting the peritoneal cavity contents with the laparoscope and a grasper in the general region of where we suspected the wire to be, based on static X‐ray images. This approach was unsuccessful, in part due to the fact that the wire kept changing locations from image to image, and we were always behind on the chase.The use of live fluoroscopy allowed us to eventually align the jaws of the laparoscopic grasper over the opaque wire. The surgeon accomplished this by looking just at the fluoroscopy monitor and not the laparoscopy screen. Afterward, attention was turned back to the laparoscopy screen, and the tissue immediately under the grasper was retracted upward. In this case, it was the omentum. The final key maneuver was another three seconds of live fluoroscopy, during which the surgical team jiggled the grasper (presumably holding the foreign body) and simultaneously observed both screens to ensure that the grasped object moved in concert under both live fluoroscopy and laparoscopy Figure C and 1D.Overall, retained wires are a relatively uncommon phenomenon among thousands of users who wear sensors. As reported in 2011, it is believed to occur in 0.03% of sensors shipped.In retrospect, the fact that an abdominal X‐ray, which was taken in the emergency room, showed the second wire on the contralateral side from its insertion site might have served as a clue to its mobility. During the case, we could also directly see the needle enter the peritoneum during laparoscopy Figure A. This sDr Lal has consulted for GlySens Incorporated and Abbott Diabetes Care. Dr Buckingham has received research support for PI‐initiated studies as well as sensors at a research discount for closed loop studies from Dexcom.Adam Sang: wrote and edited the manuscript; Rayhan Lal and Auriel August: edited and reviewed the manuscript; Enrico Danzer and Bruce Buckingham: revised the manuscript; and Claudia Mueller: conceived the case report, and edited and revised the manuscript.


Bladder injury is an uncommon complication of cesarean delivery (CD) with an incidence ranging from 0.0016% to 0.94%. The risk factors are emergency CDs, subsequent CDs, trial of normal delivery after CD and whether adhesions are present or not. The presentation is either immediate intraoperative event or delayed bladder rupture and urinary ascites.A 35-year-old female presented with considerable abdominal distension, shortness of breath, oliguria, straining to void and elevated levels of blood urea and serum creatinine 11 days after an uneventful Caesarean delivery. Abdominal ultrasound showed marked ascites. Immediate resuscitation was done, a urethral catheter and percutaneous intraperitoneal pigtail catheter were inserted confirming urinary ascites. Next day cystoscopy was performed and revealed a perforation at the posterior wall of the bladder. She was kept on conservative treatment with adequate urine diversion through both urethral and intraperitoneal catheter. Her condition improved and responded well.To the best of our knowledge this presentation of delayed intraperitoneal bladder rupture post CD is the second case reported in literature. Although surgical repair is regarded as the treatment of choice for intraperitoneal bladder injury, conservative treatment may succeed in properly selected cases. Non-operative managements include indwelling transurethral Foley catheter alone, percutaneous peritoneal drain alone or combined Foley catheter and percutaneous peritoneal drain for complete urinary drainage.Delayed urinary bladder rupture is a very rare complication of cesarean delivery. Non-operative treatment can be a viable alternative to surgical repair in carefully selected patients. Cesarean Delivery (CD) is amongst the procedures that carry low risk for bladder injury, with incidence ranging from 0.0016% to 0.94% . Most of2A 35-year-old healthy pregnant lady with a history of 3 previous cesarean sections was scheduled for her 4th cesarean delivery. The operation was performed under spinal anesthesia. Severe adhesion of the urinary bladder to the lower uterine segment was encountered but there was no apparent lower urinary tract injury. Her postoperative period was uneventful and she was discharged home the next day. On the 11th postoperative day she was readmitted to the emergency unit at 11 pm with considerable abdominal distension, shortness of breath and difficulty of micturition with straining to void. Further questioning revealed sudden inability to void 5 days earlier followed by mild hematuria and passing a small amount of urine. On examination she was dyspneic, the abdomen was distended, pulse rate was 100 BPM, blood pressure was 100/60 mm/Hg and afebrile. Immediate resuscitation was started and Foley catheter was inserted which drained 100 ml concentrated urine. Serum creatinine (6.8 mg/dl), blood urea (123 mg/dl) and serum potassium (5.6 meq/l) were high. Abdominal and pelvic ultrasound showed marked ascites , normal 3Bladder injury is an uncommon complication of cesarean delivery. The mode of presentation is either intraoperative occurrence which is seen in most of the cases or delayed bladder perforation post cesarean delivery. The latter is very rare, in which the patient presents with urinary ascites and elevated serum creatinine due to its reabsorption through the peritoneal membrane, mimicking acute kidney injury. Tai CK et al reported the first and the only case of delayed bladder rupture 14 days after cesarean section. They postulated the mechanism of the perforation to be due to partial mural tear by diathermy or retraction during separation of the bladder from the lower uterine segment. This will lead to the formation of a weak point that may become a full thickness perforation during straining . The samThe standard imaging technique for the diagnosis of bladder injury is retrograde cystography with a reported accuracy of 85%–100%, but there are still reports of false negative results especially in cases with small perforations and inadequate bladder distension with contrast material. In these cases CT cystogram is an alternative where even a small amount of contrast extravasation can be detected [Although surgical repair is regarded as a standard care for intraperitoneal bladder injury, there are multiple successful trials of nonoperative management in the literature; among them are intraperitoneal bladder perforations during transurethral resection of bladder tumor, spontaneous bladder rupture and bladder rupture due to blunt trauma. Nonoperative management includes indwelling transurethral Foley catheter alone, percutaneous peritoneal drain alone or combined Foley catheter and percutaneous peritoneal drain for complete drainage . In the 4Delayed urinary bladder rupture is a very rare complication of cesarean delivery. It may present as urinary ascites causing elevated blood urea and serum creatinine mimicking acute kidney injury. Non-operative treatment can be a viable alternative to surgical repair in carefully selected patients.There is no conflict of interest.None to be stated.Approval has been given by Ethical committee of University of Sulaymanyiah.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.Operating surgeos: Ismaeel Aghaways, Nishtman M. Thahir, Rawa BapirDesign and idea: Ismaeel Aghaways, Rawa Bapir, Tahir A. Hawrami, Nishtman M. Thahir, Mohammed Abed Al Kadum Hassan and Karzan Mohammed Salih Hassan.Drafting: Rawa Bapir, Ismaeel Aghaways and Tahir A. HawramiData aquision: Rawa Bapir, Karzan Mohammed Salih Hassan, and Nishtman M. ThahirFinal revision: Tahir A. Hawrami, Rawa Bapir, Nishtman M. Thahir, and Karzan Mohammed Salih.Not applicable.The corresponding author is the guarantor of submission.Not commissioned, externally peer-reviewed.


A 58-year-old female with the prior history of diabetes mellitus (DM) presented with nausea, malaise, and abdominal pain of two days duration. Also, in the past, she was treated for a necrotized rectum from a retroperitoneal infection leading to a colostomy in the left lower quadrant (LLQ) of the abdomen. The physical examination findings were highly suggestive for a parastomal hernia. As a part of her workup and treatment, the initial abdominal CT demonstrated the presence of the gastric contents into the hernia sac leading to the gastric obstruction. The patient responded well to the conservative management using nasogastric (NG) suction, intravenous (IV) line maintenance, clinical assessment, frequent vital sign monitoring, and initiating the nothing per oral (NPO) regimen. Following the successful conservative approach, the patient opted to undergo surgical treatment in the future. This case report and associated literature search represent a rare case of a parastomal hernia with protruding gastric contents, which was successfully treated with conservative management. A parastomal hernia is a common late complication of ostomy creation, permitting gastrointestinal contents to protrude through an ostomy site , 2. The Likewise, the clinical presentation of patients with a gastric parastomal hernia (GPH) depends on the functional status of the gastric contents in the sac . PatientFurthermore, CT of the abdomen is the most widely used diagnosed test for the diagnosis of the GPH , 7. AlthConsidering the rarity of this condition, we performed a comprehensive literature search Table  and surpA 58-year-old woman with a long-standing history of the type 2 diabetes mellitus (DM) presented to the emergency department (ED) with a two-day history of nausea, vomiting, and moderate to severe burning abdominal pain. She additionally noted increased liquid consistency of her stools as well as increased output from her colostomy bag. Her past medical history included a severe necrotized rectum from a retroperitoneal infection requiring a colostomy in left lower quadrant (LLQ) abdomen - also, her family and social history were insignificant.9/liter with 70.5% of granulocytes.At the initial presentation, she was afebrile with a blood pressure of 147/77 mmHg, a heart rate of 93 beats/minute, a respiratory rate of 19 breaths/minute, and an oxygen saturation (SpO2) of 97%. Physical examination revealed moderate generalized abdominal tenderness without the signs of peritonitis. Also, a well-appearing LLQ ostomy site without any signs of ischemia and a bulge around the stoma was noticed. Laboratory findings were unremarkable except for an elevated glucose level and her initial white blood count (WBC) of 11.4 × 10Based on the findings of the physical examination, a CT of the abdomen and pelvis was performed, which demonstrated a parastomal hernia causing a partial small bowel and gastric obstruction. Likewise, the parastomal hernia contained a portion of the stomach, small intestine, colon, and mesentery Figures , 2, confInitially, a conservative approach including an NG tube insertion, IV hydration, serial clinical assessment, and frequent vital signs monitoring, was initiated. Also, based on the patient’s clinical condition, the nothing per oral (NPO) regimen was ordered. The patient promptly started responding to the conservative management on day 1 with the improvement of her symptoms. On day 2, the patient felt much better with the improvement in the abdominal pain and no nausea and vomiting. At this point, the NG tube was removed, and her diet was gradually progressed to a soft food diet.The additional monitoring of the patient was fairly gratifying. She tolerated the soft diet without any difficulty, other discomforts, nausea, and vomiting. To evaluate the status of her intestinal obstruction, the abdominal X-ray (XR) was ordered, which showed no further evidence of a small bowel obstruction. In the meanwhile, the alternative plan of surgical intervention was also discussed with the patient. The patient showed progressive clinical improvement over the following few days and desired a follow-up appointment with her surgeon after the discharge from the hospital. She was discharged with a plan to follow up with her surgeon from an outside hospital to discuss surgical treatment options for the parastomal hernia.A parastomal hernia is a common complication following EC 4.0-48.1%), end ileostomy (EI) 1.8-28%), loop colostomy (LC) 0-30.8%), and loop ileostomy (LI) (0-6.2%) [8%, loop 0.8%, and.0-48.1%,In an effort to better understand the rarity of the gastric herniation into the hernia sac, Ellingson et al. in a case report reported that stomach is usually held tightly into the abdominal cavity by the numerous ligaments . They liAdditionally, the clinical presentation of GPH varies according to the extent of gastric involvement . Mostly,Although the diagnosis of the GPH is mostly established on the high clinical suspicion and finding on the physical examination, nevertheless, the advancement in radiological imaging has allowed a better delineation and improved detection of this rare entity. The abdominal CT scan has been frequently used not only for the detection of parastomal hernia and its contents but also it adds in detecting the complications associated with the GPH including gastric perforation and emphysema , 7. AlthFurthermore, the treatment of the uncomplicated partial GPH is usually conservative, followed by the elective surgical intervention , 10. In To expand our knowledge regarding the rarity of this clinical entity, a Boolean Logic literature search of the PUBMED database was conducted using a combination of the keywords including “parastomal hernia”, “peristomal hernia”, “incarcerated peristomal hernia”, “colectomy”, “transverse colectomy”, “gastric hernia”, “stomach” and “gastric”. A total of 13 results were found from the PUBMED database, which was further analyzed. Out of these 13 results, only 11 case reports were identified as having parastomal hernia with the gastric contents (Table GPH is a rare clinical finding mostly affecting female after the 5th decade of life with a previous history of colostomy or ileostomy formation. A high degree of clinical suspicion along with the use of CT scan abdomen is the key in making a timely diagnosis. The conservative management should be promptly initiated in a patient with uncomplicated GPH, while the urgent surgical treatment should be reserved for the life-threatening cases. Also, large scale institutional studies should be carried out in order to better understand this rare disease.


Abdominal pain is a common clinical challenge presenting to the emergency department. The challenge lies in the wide differentials particularly in females due to the addition of potential gynecological conditions. Ovarian vein thrombosis (OVT) is one of the uncommon differentials requiring rapid recognition & treatment to avoid serious complications or even death.We report a 42-year-old healthy female, post normal vaginal delivery 1- year prior to presentation. She presented with left iliac fossa and periumbilical pain for 1-day with no other symptoms. She was vitally stable. Abdominal & pelvic examinations revealed left lower tenderness with guarding. Laboratory investigations were within normal. Abdominal Doppler showed a dilated left ovarian vein with absent flow and Computed tomography (CT) scan confirmed the presence of a thrombus. Therefore, the diagnosis of OVT was made and she was started on anticoagulation.OVT is a rare, life-threatening condition occurring mainly during the post-partum period . Diagnosing ovarian vein thrombosis can be challenging because of the overlapping presentation with other differentials. A high index of suspicion should be kept in females presenting with abdominal pain. Standard guidelines for managing OVT are lacking. However, lower limb DVT guidelines have been suggested in the literature to be applicable.The initial modality of diagnosing OVT is Doppler ultrasound. However, CT and MRA confirm the diagnosis in case of uncertainty. The mainstay of treatment is the conservative approach while the surgical approach is reserved for persistent OVT despite appropriate conservative therapy. The challenge lies in the wide differential diagnoses particularly in female patients due to the addition of potential gynecological conditions such as ovarian torsion, ovarian cyst and ovarian vein thrombosis. Ovarian vein thrombosis (OVT), if not diagnosed or treated early, can be complicated by sepsis and pulmonary embolism in 25% of the cases, which increase the mortality rate up to 4% [2Herein, we report a case of a 42-year-old female, medically free, with 5 previous normal vaginal deliveries, last delivery was 1 year prior to presentation. She was in her usual state of health until she presented to our emergency department complaining of sudden left iliac fossa and periumbilical pain associated with nausea and constipation for 1-day. The pain was not radiating with no aggravating or relieving factors. There was no fever, dysuria, hematuria or vaginal discharge. Her menstrual period was regular. She had no history of hypercoagulability or previous thromboembolic events as well as no history of previous surgery. Upon examination, she was afebrile & hemodynamically stable. Abdominal examination revealed left lower tenderness with guarding, with no palpable masses nor organomegaly. Her pelvic examination was unremarkable. Laboratory investigations showed no leukocytosis, negative C-reactive protein & Beta human chorionic gonadotropin with normal coagulation profile & a negative urine analysis. Transabdominal ultrasound of the left ovary showed dilated left ovarian vein  A & B. D3Ovarian vein thrombosis (OVT) is a rare yet, a life-threatening condition. It occurs mainly during the post-partum period with an incidence of 0.18% post normal vaginal delivery & in 2% after caesarian section . The assgold standard guidelines are lacking. However, Wysokinska et al. suggested that lower limb DVT guidelines are applicable ,9. The d4Although OVT is a rare condition occurring mainly in post-partum women, it should be kept in mind as a differential diagnosis for iliac fossa pain. Abdominal Doppler ultrasound should be done first to diagnose OVT, however, contrasted CT and MRA have a higher sensitivity and specificity. The mainstay of treatment is the conservative approach by using antibiotics (if indicated) and anticoagulants, while the surgical approach is reserved for patients with persistent OVT despite appropriate conservative therapy.None.None.Case reports are exempt from the need of IRP approval in our institute.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.Literature review: Riyadh Al Abbas, Abdullah AlQattan, Muntadhar Alalqam, Fatimah Almabyouq, Abdaljaleel Abualsaud.Data collection: Riyadh Al Abbas, Fatima Almabyouq.Writing of manuscript & reviewing of the final version of the manuscript: all authors.Not applicable.Muntadhar M. Alalqam.Not commissioned, externally peer-reviewed.


A four-year-old girl presented with fever and a painful limp in the left hip. Pain characteristics and anemia detected in the blood analyses were the first warning signs that the hip process was not standard. Although the primary suspicion was of septic arthritis, a CT scan of the abdomen revealed an adrenal neuroblastoma.  The presenting signs of neuroblastoma are commonly atypical. About 25% of presentations are orthopedic and mimic a variety of severe orthopedic conditions. The most important clinical dilemma is distinguishing benign and self-limiting disorders from septic or malignant processes. Neuroblastoma is an embryonic tumor of the peripheral sympathetic nervous system and the most common extracranial solid tumor of childhood, accounting for 8% of childhood malignancies , 2. It hA four-year-old girl presented to the emergency service with painful left hip and fever. There was no previous relevant medical history. There were no other local or systemic symptoms, except for a cervical adenopathy. On physical examination, she walked with a limp, and movements of the left hip were painful , but not restricted. Blood exam revealed anemia (Hb 8.7 gr/dL), normal WBC, ESB of 123 mm, and reactive C protein of 149.7 mg/L. An initial X-ray to the pelvis revealed no changes. An ultrasound of the left hip was performed revealing small infusion and synovitis. Guided puncture was then performed being macroscopically compatible with reactive arthritis, and general and bacteriological tests were demanded. Because of the unusual characteristics of the pain, a CT scan to the abdomen and pelvis was performed revealing a left adrenal mass and retroperitoneal adenopathies in the celiac trunk and superior mesenteric artery .Despite the painful complaints of the patient, no bone or articular involvement was found in the CT scan. No further alterations were reported in the thoracic CT scan or in peripheral blood smears. Bacteriological examination of the hip effusion was negative. MRI was also performed. The direct myelogram was compatible with infiltration from neuroblastoma. Bone marrow biopsy and cervical adenopathy specimens were collected to perform histological diagnosis. Skeletal scintigraphy demonstrated numerous points of osteoblastic activity compatible with metastatic activity, and the 12 iodine-123 metaiodobenzylguanidine scintigraphy concluded the following: “Abdominal mass with low expression of noradrenergic transporters. Diffuse bone metastasization with high expression of noradrenergic transporters. No other soft tissue involvement was detected.” In the histological report of the cervical adenopathy, the diagnosis of neuroblastoma NOS was performed. Immunohistochemistry revealed extensive expression for synaptophysin and CD56 (NCAM) and absence of expression of myogenin. .Bone marrow biopsy revealed extensive metastatic involvement. The patient started chemotherapy two weeks after admission, with 8 cycles of rapid COJEC protocol. After six months of follow-up, the primary tumor was still without criteria for resection, despite a decrease in the metastatic involvement. Given the chemotherapy-related renal toxicity, it was decided to proceed with irinotecan in combination with temozolomide (TEMIRI). After thirteen months of follow-up, no significant regression of the primary tumor occurred, so surgery was contraindicated and the patient was proposed for stem cell treatment.Hip pain is not uncommon in childhood . The mosWong et al. and Huttenlocher and Newman found that a high erythrocyte sedimentation rate (ESR) (>50 mm/h) was a surprisingly good indicator of serious disease in children, particularly in patients presenting with a limp , 15. SevIn childhood, neuroblastoma often involves the musculoskeletal system and mimics a variety of orthopedic problems at presentation. The history and physical examination can be misleading and haematological and X-ray investigations are usually inconclusive . This ca


Despite modern investigative innovations in the cutting edge field of gastroenterology, we are reminded of our contemporary limitations when we encounter the ever evasive Dieulafoy’s lesion (DL). Ever since it has been initially described in 1884, its rare but frustrating presence creates a calamitous situation. Even more so when it presents atypically, much like it did in our patient. This review of DL delves into the history, epidemiology, characteristics, the most current and innovative diagnostic measures available, as well as treatment and prevention of recurrence of these obscure gastrointestinal (GI) bleeding sources. There is a cognitive bias when one has a new experience or learned something new and suddenly one begins to encounter it more frequently, even if its been there all along. This phenomenon, known as Baader-Meinhof, becomes most crucial in the dissemination of academic literature about rare entities such as Dieulafoy’s lesion (DL). By parlaying information about DLs to investigators or endoscopists, it forces them to not only intelligibly discern these esoteric submucosal defects that can readily go unnoticed, but also actively search for it with every withdrawal of the scope to determine the etiology behind obscure gastrointestinal (GI) bleeding. This review will serve to explain the history, epidemiology, characteristics, the most current and innovative diagnostic measures available, as well as treatment and prevention of recurrence of DLs.An 87-year-old female patient with a history of gastroesophageal reflux disease (GERD), gastritis, diverticulosis and chronic non-steroidal anti-inflammatory drugs (NSAID) use presented with melena, diffuse abdominal pain and non-bloody, non-bilious emesis. In the setting of her acute anemia with hemoglobin (Hb) of 5.9 g/dL and tachycardia, an esophagoduodenoscopy (EGD) demonstrated a single medium-sized DL in the second portion of the duodenum next to the major papilla oozing blood that was controlled with a bipolar diathermy Figures -2. DailyDLs are dilated submucosal veins that are exposed to the surface and endoscopically visualized as bleeding points without surrounding erosions or ulcerations. It accounts for 1% to 5.8% of cases of acute nonvariceal upper GI bleeding   can be found in the proximal stomach, particularly 6 cms from the gastroesophageal junction ,6. LesioPatients with DLs are typically asymptomatic but then can present acutely with massive GI hemorrhage ,6-8. BleDiagnosis remains challenging as urgent EGD is indicated, but without an ulcer base to guide identification, diagnosis on an initial endoscopy can be as low as 49%; 33% of those affected require a repeat endoscopy and 18% require an exploratory laparotomy ,9 (PosteTreatment is a two-pronged approach since the recurrence rate of a DL can range from 9% to as high as 40%. Primary hemostasis can be achieved with electrocoagulation, which provides a quick and inexpensive solution with an almost 80% hemostatic success rate . EquivocDLs incur healthcare costs from numerous tests and hospital visits and increases aggravation due to its difficulty in diagnosis and delay in prompt treatment. Numerous available modalities, such as push enteroscopy as an extension of an EGD and side-viewer endoscope, aid in diagnosing DLs in anatomically difficult locations. However, the ability to recognize them lies in the endoscopist's scope of discernation. We hope this review coupled with the Baader-Meinhof phenomenon increases the perception of this rarely occurring pathology.


Obturator hernia is rare. It occurs when part of the pelvic contents protrude through the obturator foramen. It is a diagnostic challenge in the emergency department since the signs and symptoms are non-specific. It often occurs in elderly, emaciated and chronically ill women. The clinical picture include intestinal obstruction with abdominal pain, nausea and vomiting. The treatment is only surgical. Delayed diagnosis of this condition usually leads to a high mortality rate. We report the case of an 83-year-old woman with a strangulated obturator hernia. The hernia was discovered early by computed tomography and was treated by emergency laparotomy. We emphasize on the rule of CT scan to establishing a prompt preoperative diagnosis of an obturator hernia, appropriate planning of surgical intervention and thus optimizing the outcome. Obturator hernia is a rare abdominal wall hernia with incidence of 1% . It mostA frail 83-year-old woman was admitted with a 48 h history of acute abdominal pain, absolute constipation and vomiting. She had type 2 diabetes and had never undergone abdominal surgery. She reported two episodes of colicky hypogastric pain with lower abdominal swelling in the last few weeks that resolved spontaneously. There is no pain in the lower limbs especially in inner thigh or the knee. Clinical examination showed a moderate built patient with a temperature of 37.7°C, dry tongue and sunken eyes. On local examination, she had a distended abdomen with generalized tenderness and no groin hernias. Other systems were essentially normal. Rectal examination and bloods were unremarkable. Plain X-rays revealed dilated bowel loops with multiple central air-fluid levels suggestive of complete small bowel (SB) obstruction with no signs of perforation. Urgent CT scan of the abdomen and pelvis performed with contrast . It reveObturator hernias are characterised by bowel herniating between the obturator and the pectineus muscles. They are a rare type of abdominal hernia. With the nickname “little old lady's hernia”, they are often seen in elderly, chronically ill and thin women . The heret al. in 1983 [Howship-rhomberg sign is pain radiating down the medial aspect of the thigh to the knee and less often to the hip caused by compression and irritation of the obturator nerve within the canal, this pathognomonic sign is seen in 15-20% of patients. Because symptoms are nonspecific and determined physical findings are often absent, diagnosis of obturator hernia usually delayed until laparotomy performed for treatment of bowel obstruction or peritonitis. Various imaging tools have been formerly used to establish the diagnosis, including barium enema fluoroscopy, ultrasonography and herniography. Actually, emergency multidetector CT scanning could lead to rapid diagnosis and early surgical intervention and thus optimizing the outcome. The use of CT scan in detecting obturator hernia was first reported by Meziane .An obturator hernia is very rare and difficult to diagnose. It occurs when part of the pelvic contents protrude through the obturator foramen. In elderly and chronically ill women with signs of bowel obstruction, this type of hernia must be considered. Abdominal CT scan is actually the best diagnosis tool.The authors declare no competing interests.


Pediatric pancreatic teratoma (PPT) is a rare tumor with unclear clinicopathologic features and treatment strategy.A 13-month-old boy was admitted to the hospital with a complaint of a palpable epigastric mass.The lesion was diagnosed as benign mature cyst teratoma via postoperative pathological examination.Pylorus-preserving pancreaticoduodenectomy (PPPD) was performed on the patient. The entire mass was resected from the head of the pancreas and sent to the laboratory for frozen section evaluation.The patient was followed up for 15 months. He did not undergo recurrence or PPPD-related complications.The differential diagnosis of retroperitoneal occupying lesions among children must consider mature cystic teratomas. Compete surgical resection combined with subsequent postoperative outpatient follow-up remains the primary choice for the management of PPTs.PPTs are extremely rare tumors with unclear clinicopathologic features and treatment strategy. This study aims to explore the clinical characteristics of and treatment strategy for these tumors. We reported a 13-month-old patient with pancreatic teratoma who underwent pylorus-preserving PPPD. The operation lasted approximately 6 hours. The mass was completely removed, and the patient recovered uneventfully. Complete surgical resection combined with outpatient follow-up is the primary choice for the management of PPTs. However, teratomas derived from the pancreas are exceedingly rare among the pediatric population, resulting in difficulty in their preoperative diagnosis and treatment. Herein, we present the case of a pediatric patient with mature teratoma of the pancreatic head and who underwent pancreaticoduodenectomy (PD). We explore the safety and efficacy of PD for pediatric patients with teratomas in the pancreas to further understand this rare tumor.Teratomas are common germ cell tumors among the pediatric population and are composed of tissues originating from all 3 dermal layers: endoderm, mesoderm, and ectoderm.This study was conducted in accordance with the principles outlined in the Declaration of Helsinki and authorized by the Ethics Committee of the hospital. Written consent was obtained from the parents before operation.2A 13-month-old boy was admitted to the institute due to a palpable abdominal mass that was incidentally noted by his mother during child health service. His physical examination was unremarkable, with only a round, hard, elastic, and rigid mass in his upper abdomen without tenderness. The parents did not complain of any discomfort or special family history. A solid cystic mass was revealed by abdominal contrast-enhanced computed tomography (CT) and magnetic resonance (MR) scans at the right side of the mid-upper retroperitoneum Figs. . The tumAn exploratory laparotomy was performed after preparation prior to surgery. During operation, intraoperative findings displayed a huge mass originating from the pancreatic head with high surface tension and a complete capsule. The duodenum and superior mesenteric vessels were involved, making the separation of the lesion from the surrounding involved tissue difficult. A subsequent pylorus-preserving pancreaticoduodenectomy (PPPD) procedure was ultimately performed on the patient. The entire mass was resected from the head of the pancreas and sent to the laboratory for frozen section evaluation.In our case, gross pathological evaluation presented a mass that was 12 cm × 9 cm × 8 cm in size. Histologically, the mass contained abundant keratinous debris and components of adipose tissue, cartilage, and hair follicle. The morphological features were consistent with a mature cystic teratoma of the pancreas, a type of benign tumor Fig. . TeratomPostoperatively, the patient developed fever and pulmonary infections that required antibiotic treatment of bacteremia but did not experience PPPD-associated mortalities, such as pancreatic leak, delayed gastric emptying, and fat malabsorption. The boy was discharged on postoperative day 22. At 3 months postoperative, the AFP level decreased to normal range, and the patient did not complain of any discomfort.3 first described pancreatic teratoma in 1918. To date, 9 pediatric patients with pancreatic teratomas have been reported in the English-language literature, as summarized in Table Kerr Therefore, postoperative pathological evaluation remains the primary diagnostic approach.The preoperative diagnosis of PPT is difficult. In several cases, the characteristic of fat and calcium combination in the radiologic appearance of magnetic resonance/computerized tomography (MR/CT) is considered highly predictive of mature teratomas. In our case, however, MR and CT only revealed the position and shape of the tumor without this characteristic. Similarly, tumor markers, such as enolase (NSE), carcinoembryonic antigen, and CA-199, lack specificity and sensitivity, except for serum AFP, the level of which is suggestive of disease activity. Endosonography-guided fine needle aspiration biopsy is proposed to help in the preoperative diagnosis of pancreatic tumors; however, this technique is limited by lack of equipment and expertise. PD is a common procedure in the treatment of numerous benign and malignant pancreatic or periampullary diseases. To our knowledge, PD is a rare procedure among the pediatric population because of the low rate of periampullary diseases in this population and the possibility of growth retardation. Notably, PD may lead to impaired exocrine and pancreatic endocrine functions and gastrointestinal problems. Thus, the postoperative endocrine and exocrine functions of the pancreas and the digestive function must be evaluated; moreover, serum AFP level and quality of life must be closely monitored during follow-up.–16With regard to treatment, surgical resection is the mainstay of therapy for PPTs, but detailed surgical guidelines are unavailable. In general, complete surgical resection without damaging vital structures is recommended, while incomplete resection is associated with poor oncological outcome. The operation procedure is determined on the basis of tumor location.In conclusion, PPTs are exceedingly rare tumors. Complete surgical resection combined with follow-up remains the primary treatment. PD is a safe and efficient method for the management of these tumors but must be performed by a surgeon with sophisticated expertise.The authors gratefully acknowledge the whole staff of the Department of Gastrointestinal Surgery, West China Hospital, who generously provided assistance in the collection of data throughout the duration of the study.Conceptualization: Yuan Yin, Bo Zhang.Data curation: Jian Wang, Yuan Yin.Methodology: Yuan Yin, Zhaolun Cai, Chaoyong Shen, Xiaonan Yin, Xin Chen, Zhou Zhao.Supervision: Bo Zhang.Validation: Bo Zhang.Writing – original draft: Jian Wang.Writing – review & editing: Bo Zhang.Bo Zhang orcid: 0000-0002-0254-5843.Jian Wang orcid: 0000-0001-7388-7368.


Primary extranodal lymphoma is defined as a lymphoma at a solitary extranodalsite, with or without involvement of the lymph nodes. The clinical andradiological features of extranodal lymphoma have been documented in recentstudies. In this pictorial essay, we reviewed imaging findings of extranodallymphoma in the head and neck region. Extranodal lymphoma of the head and neck can affectthe paranasal sinuses, nasal cavity, salivary glands, thyroid gland, or orbit.Lymphoma is the most common nonepithelial malignancy of the head and neck region.Non-Hodgkin lymphomas are found in extranodal regions outside the lymphoid system in40% of cases. The clinical features, computed tomography (CT) findings, and magneticresonance imaging (MRI) findings of extranodal lymphomas in the head and neck regionhave been described. The most common types of ocular lymphoma areextranodal marginal zone lymphoma and mucosa-associated lymphoid tissue lymphoma,other types including follicular cell, mantle cell, diffuse large B-cell, andlymphoplasmacytic lymphoma(4). Lymphoproliferative disease of the orbitencompasses a spectrum from benign (reactive) lymphoid hyperplasia to malignantlymphoma, the most common clinical symptoms being exophthalmos, eyelid swelling, anddiplopia(4).Lymphoid tumors usually occur in lymph nodes but can involve extranodal sites,including the orbits. Ocular lymphoma is a malignant lymphoproliferative neoplasmthat affects the eyelid, conjunctiva, orbit, or lacrimal gland, accounting for 30%of orbital tumors(1). It is typically located near the lacrimal gland inthe upper outer quadrant of the orbit. A soft-tissue mass surrounding theextraocular muscles is helpful in distinguishing lymphomas from other orbitalmasses(2). On CT, orbital lymphoma is isodense to the extraocularmuscles .Orbital lymphoma is seen as a well-defined soft-tissue mass in theorbitmuscles  and 2. Omuscles , as well(6). It is a rare malignancythat is intrinsically associated with Hashimoto’s thyroiditis. It presents as agoiter, accompanied by pressure symptoms, and it is necessary to make a rapid,accurate diagnosis. The most common clinical presentation of thyroid lymphoma is arapidly growing goiter and compressive symptoms, including dyspnea, stridor,hoarseness, and dysphagia(7). The histological subtypes of thyroid lymphoma arediffuse large B-cell lymphoma and mucosa-associated lymphoid tissue lymphoma.Primary thyroid lymphoma is rare, accounting for only approximately 5% of all thyroidmalignancies and less than 3% of all extranodal lymphomas: nodular, diffuse, or mixed. CT can be used inorder to assess involvement of surrounding structures and to facilitate accuratesurgical planning, as well as to diagnose cervical and mediastinal lymph nodedisease. In one study of patients with primary thyroid lymphoma, Kim etal.(9)reported that none of the patients showed tumor invasion into the adjacent commoncarotid artery or surrounding muscle, as was confirmed during surgery.Ultrasound is the imaging modality of choice for thyroid lymphoma and can typicallyshow one of three patterns(10). Necrotic degeneration and calcification are rarein a thyroid lymphoma. On MRI, patients usually present with a rapidly enlargingthyroid mass and obstructive symptoms related to compression of the aerodigestivetract, and the signal intensities on T1W and T2W images are isointense relative tothe neck muscles. For staging, restaging or assessing the response to treatment inthyroid lymphoma, 18F-fluorodeoxyglucose positron emission tomography/CT(18F-FDG-PET/CT) can be useful(11)  .(12). Diffuse large B-cell lymphoma, the most commontype of lymphoma, and natural killer/T-cell lymphoma, nasal type, are highlyprevalent in Asians(12-14). In sinonasal lymphoma, the spectrumof clinical symptoms encompasses nasal obstruction, rhinorrhea, epistaxis, postnasaldrip, facial swelling, neck mass, fever, and weight loss. The differential diagnosesinclude sinonasal carcinoma, olfactory neuroblastoma, and Wegener’s granulomatosis.Sinonasal lymphoma presents as a diffuse infiltrative soft-tissue mass extendingalong the paranasal sinus and nasal cavity. On CT, it appears as a soft-tissue massthat is isodense to muscle tissue (15.Hematolymphoid lesions account for approximately 12-17% of all malignant neoplasms inthe nasal cavity and paranasal sinuses. Squamous cell neoplasms are the most commonsinonasal malignanciese tissue .CT is ue tissue , whereasPrimary extranodal lymphomas are rare and can mimic other neoplasms or inflammatoryconditions. Lymphomas should be included as a major differential diagnosis of asoft-tissue mass and can be identified through the use of CT or MRI.


Rhinophyma is an uncommon subtype of rosacea, the clinical diagnosis of which is straightforward. However, localized, especially well-circumscribed, rhinophyma is a very rare condition, which requires a paraclinical assessment to be accurately diagnosed.We report a 48-year-old male patient who presented with a well-circumscribed and dark red tumoral mass of 28 mm in diameter and smooth consistency in the right nasal ala. The patient had no former and concomitant characteristic skin lesions on the other part of his face. Histopathology and immunohistochemistry assessments documented the diagnosis of rhinophyma. 2 laser in a fast and efficient manner with esthetically satisfactory outcome and no significant complications.To the best of our knowledge, this is the first case report of well-circumscribed localized rhinophyma. This lesion can be treated by CO Rhinophyma is the most common presentation of phymatous rosacea that mostly occurs in the nose of men. Patients with rhinophyma often have former and concomitant clinical features of rosacea, such as papule, pustule, erythema, and telangiectasia, or it may originally occur without any previous skin lesions ,2. Rhinophyma is clinically characterized by a large, erythematous, and bulbous nose with dilated pores, telangiectasia, and soft, fleshy, and nodular growth ,3. The hLocalized rhinophyma is an unusual form of rhinophyma . Well-ci2 laser with excellent cosmetic outcomes. Treatment of rhinophyma includes oral isotretinoin, cryosurgery, dermabrasion, surgical excision, and laser therapy with variable therapeutic outcomes -8. HereiA 48-year-old heavy smoker male driver with Fitzpatrick skin type III referred to our clinic with a tumoral mass in the right nasal ala having appeared for 18 months . In his past medical history, he had no skin lesions or systemic problems. Physical examination revealed a well-circumscribed, dark red, smooth, and consistent tumoral mass with dilated pore and sparse telangiectasias of 28 mm in diameter in the right nasal ala . There wThe histopathologic findings of the skin lesion biopsy, performed twice over a year, were nonspecific. However, histopathological assessment of the incisional skin biopsy revealed the telangiectasia of superficial dermal vessels with perivascular infiltrate of lymphocytes and a few plasma cells. Sebaceous gland hyperplasia, perifolliculitis, and Demodex mites in pilosebaceous follicles were also noticeable .2 laser treatment for the ablation of the lesion. Before laser therapy, a horizontal section biopsy of the whole lesion was performed to rule out the superimposition of malignancy on the rhinophyma  CO2 laser therapy using continuous cutting mode and a sharp and disposable curettage as adjuvant therapy for the removal of debris between laser passes.Madan et al. treated 124 patients with rhinophyma by high-power continuous cutting mode of CO2 laser . They co2 laser therapy and curettage as adjuvant therapy was associated with low thermal damage to the underlying and surrounding tissues of the treated area. These facilities provide easy application, few sessions, and short-term procedure with a low possibility of side effects, as well as inexpensive and acceptable cosmetic and treatment outcomes.In our method, the use of low-power CO2 laser was found to be an easy, rapid, and effective treatment of rhinophyma leading to an excellent cosmetic outcome with low risk or few complications.To the best of our knowledge, this is the first case report of WCLR. Our procedure by CO


Ethmoidal fibrosarcoma is an extremely rare tumor which represent less than one percent of all malignancies in this anatomical area, the case of a 13-year-old is reported here.A 13-year-old boy, his medical history was marked exclusively before presented to our hospital by an exophthalmia. Rhinoscopic examination showed well-defined pink mass at the level of ethmoid. Computed tomography was performed to showed local and regional extension. Treatment was an endoscopic excision of the tumor using a navigation system. The final diagnosis was made on pathologic examination. Radiotherapy was recommended by multidisciplinary staff but the patient refused.These tumors occur in extremities most frequently and Ethmoidal localization is extremely rare and have no specifics symptoms, so the rhinoscopic examination is necessary for any chronic nasal symptom. Its treatment is not codified because of its rarity and its prognosis is unknown.It’s important knowledge about this pathology because of its rarity and its therapeutic and prognostic difficulties. Occurrences in the head and neck are not common, accounting for <1% of the malignancies in this anatomical area . Clinica2A 13-year-old boy presented with a one year history of exophthalmia in the left eye, without any nasal symptoms. There was no history of local trauma or systemic disease, and he was operated on 6 months ago under a rhinoscopic approach when a marsupialization of the cyst was done with pathological examination showing characteristics of an aneurysmal cyst. He was actually admitted for recidivism of the same lesion.Clinical examination showed exophthalmia of the left eye without loss of visual acuity .Fig. 1ExRhinoscopy found a well-defined mass, sitting at the level of the left ethmoidal sinus, smooth and pink. The other side was normal .Fig. 2RhTomodensitometry showed an oval multiloculated lesion more extensive in the anteroposterior plan replacing the ethmoidal cells measuring 39 × 23 × 35 mm. This lesion has regular walls, duplicated by place. Its content is made of multiple stalls with a liquid level realized by blood outside as it pushes the globe and the right internal muscles without signs of invasion, responsible for an exophthalmia grade I. Inside it fills the nasal fossa and pushes the septum without a free interface. At the top it displaces the ethmoidal roof inward without endocranial invasion. It is responsible for fluid retention at the level of the left maxillary sinus, and through posterior ethmoid cells invasion it is responsible for the narrowing of the optical channel, whereas the frontal and sphenoidal sinuses are free .Fig. 3OvSurgical intervention involved the total excision of the tumor with all its walls, in addition to the orbital medial wall and its periorbital by endoscopic approach. This was assisted by ENT navigation system which was helpful to determine the skull base, the orbit and the carotid canal because landmarks are modified by the tumor .Fig. 4NaHistopathology found fusocelular carcinomatous proliferation in the herring bone with calcification, presence of multinucleate elements showing atypia estimated at 3/10 fields. Those tissues are negative for desmin and CD 34 and positive for vimentin .Fig. 5 .Early signs and symptoms are unfortunately vague and may mimic minor upper respiratory infections. The most common presentation for sinonasal fibrosarcomas includes nasal airway obstruction, pain, epistaxis and hypoesthesia, not one of these symptoms was present in our patient .Pathologic examination is the only way of diagnosis after imaging studies. Histologically, sinonasal fibrosarcomas are composed of hypercellular tumors with spindle shaped thin cells arranged in typical herring bone pattern . When thSurgery remains the mainstay for the treatment of fibrosarcomas. Wide local excision with radical margins is generally recommended ,18. AdjuThe greatest advantage of endoscopic surgery assisted by navigation for malignant tumors is the reduction in morbidity and length of stay, but surgical margins are not always controlled.4Fibrosarcoma is very rare tumor, especially head and neck localization, symptoms are not specific, so the rhinoscopic examination is necessary when investigating any chronic nasal symptom or exophthalmia. Its treatment and prognosis is not codified because of its rarity.Authors do not declare any conflict of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This study is exempt from ethnical approval in our institution.Written informed consent was obtained from the patient's parents 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 requestDr Zouhair and dr chaouki have participated in the papers writing and images treatement, Pr Rouadi, Pr Abada, Pr Roubal and Pr Mahtar in the rereading and final approval of the manuscript upon submission.None.Zouhair Najib.Not commissioned, externally peer-reviewed.


Trichobezoar is a condition in which hair is accumulated in the stomach forming a ball like mass. Human hair is resistant to digestion and peristalsis therefore over time it accumulates in the gastric folds. Trichophagia and trichotillomania is a psychiatric disorder in which the affected person has the tendency to pull her or his own hair and ingest it. The condition is almost exclusively seen in females.A 48-year-old lady presented for the last 6 months with epigastric pain, early satiety and weight loss. There are episodic attacks of vomiting. Abdominal examination showed a large, 30 cm × 15 cm, firm, oval shaped mass occupying the left hypochondrial region and extending below the umbilicus. The mass was mobile from side to side but not from up and down it has smooth surface. The mass was non pulsatile. The CT scan of the abdomen was taken and it showed a large oval mass with interspersed gas. Endoscopy showed a huge ball of hair occupying the whole gastric cavity and extending to the upper part of the duodenum. During laparotomy a huge hair mass extracted from the stomach.Trichobezoar is an extremely rare condition that may be encountered during the surgical practice, high index of suspicion is needed to diagnose the condition and endoscopy is still the gold standard method for investigation and diagnosis. The main treatment modality if the open surgery. All patients need psychiatric consultation and long term follow up. This condition may be seen after gastric surgery such as partial gastrectomy or may be due to pica or in mentally abnormal persons. In most affected patients the condition is associated with underlying psychiatric disorder ,2.Trichobezoar is a condition in which hair is accumulated in the stomach forming a ball like mass, when this hair extends to the small bowel is called Rapunzel syndrome. Human hair is resistant to digestion and peristalsis therefore over time it accumulates in the gastric folds and form large hair ball. Trichophagia and trichotillomania, habitual hair pulling, is a psychiatric disorder in which the affected person has the tendency to pull her or his own hair and ingest it, it is considered as a part of the impulsive disorders .Patients may present with weight loss of failure to gain weight in children, upper abdominal pain, vomiting, anemia which is usually iron deficiency anemia and painless mass in the left upper quadrant of the abdomen, mechanical intestinal obstruction. This hair ball may cause ulceration of the gastric mucosa, bleeding and perforation. A case of pancreatitis due to trichobezoar had been reported. There may be associated abnormal behavioral disorders .The condition is almost exclusively seen in females and mostly occur at young ages but cases from pediatric age groups have been reported ,10.The diagnosis is done mostly by endoscopy and visualizing the hair occupying the gastric cavity and may extend beyond the stomach ,3.CT scan of the abdomen typically shows the gastric cavity occupied by a large well defined oval mass with interspersed gas, oral contrast typically sparse within the mass, it may show associated complications like intestinal obstruction and gastric perforation ,8,11.The work of this case report has been reported in line with the SCARE criteria .1.1A 48-year-old lady presented for the last 6 months with dull aching epigastric pain, early satiety and weight loss, she has not recorded the degree of weight loss but she knows that from her clothes. There are episodic attacks of vomiting which non-bilious and not containing blood.1.2During examination the patient was thin, with no pallor or jaundice. The vital signs were normal. Abdominal examination showed a large, 30 cm × 15 cm, firm oval shaped mass occupying the left hypochondrial region and extending below the umbilicus. The mass was mobile from side to side but not from up and down it has smooth surface and was not attached to the abdominal wall. The mass was non pulsatile and we can feel between the mass and the costal margin. The bowel sounds were normal and there was no any abnormal bruit 1.3The CT scan of the abdomen was taken and it showed a large oval mass occupying the gastric cavity with interspersed gas. Endoscopy showed a huge ball of hair occupying the whole gastric cavity and extending to the upper part of the duodenum 1.4During laparotomy with upper midline incision and longitudinal gastrostomy a huge mass formed from hair and filling the gastric cavity was extracted. Multiple associate ulcer in the gastric mucosa found, biopsy taken and the histopathological examination showed no malignancy. The stomach closed in 2 layers with inner continuous and outer interrupted suturing technique using 2/0 silk suture 1.5Nasogastric tube remains inside for 2 days and the oral intake started at the third day after surgery. The patient discharged home after 5 days in a good medical condition.2Trichobezoar should be treated surgically to relieve the symptoms and to prevent complications. High index of suspicion is required to diagnose this condition .Cases pf primary trichobezoar in the jejunum or the terminal ileum have been reported without any portion inside the stomach .Most cases are treated with surgical extraction of the hair by the conventional open surgery. The surgery can be done using the hand assisted laparoscopic technique. Endoscopy usually fail to extract the hair unless if small in size, but successful extraction may be done when using mechanical and laser fragmentation of the hair ,13.Laparotomy is still the preferred method of treatment due to the very high success rate, shorter operation time, less complications and ability to examine the whole gastrointestinal tract for possibility of fragmentation and impaction of some pieces at the small bowel .Trichobezoar is mostly associated with many psychiatric disorders such as trichotillomania, anxiety and depressive disorders, obsessive-compulsive neurosis, pica, anorexia nervosa, and body dysmorphic disorder. Most patients need psychiatric consultation and long term follow up after surgery to avoid recurrent bezoar formation although the recurrence rate is not estimated due to rarity of this condition ,4,8.2.1The patient denies at first any history of hair ingestion but after the endoscopy she said that she has history of hair ingestion for the last 5 years, after the surgery the patient was happy with the result of the operation and she accepted to have a psychiatric consultation.The author has no conflicts of interest to declare.None.The authors are the source of the funding.Ethical approval has been exempted by my institution for reporting this case.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Dr Ayad Ahmad Mohammed and Dr Sardar Hassan Arif. contributed to the concept of reporting the case and the patient data recording.Drafting the work, design, and revision done by Dr Ayad Ahmad Mohammed.Dr Ayad Ahmad Mohammed took the consent from the patient for publishing the case.Final approval of the work to be published was done by Dr Ayad Ahmad and Dr Sardar Hassan Arif.This work is case report and there is no need of registration.Dr Ayad Ahmad Mohammed is guarantor for the work.Not commission, externally peer reviewed.


BackgroundRespiratory epithelial adenomatoid hamartomas (REAH) are rare, glandular proliferations of the aerodigestive tract lined by ciliated respiratory epithelium. We report nine cases of REAH and devised a histopathological guide to differentiate these lesions from its main differentials.MethodsPatients with biopsy-proven REAH were included in the series. Lesions were removed endoscopically and sent for histopathological analysis. The macroscopic and microscopic features were reviewed.ResultsNine patients  with REAH were analysed. Findings revealed glandular proliferations lined by ciliated respiratory epithelium without metaplastic changes and intervening oedematous stroma. This is in contrast to a typically thickened epithelial basement membrane with oedematous stroma seen in nasal polyps.ConclusionREAHs are benign entities that should be included in the differential diagnosis for sinonasal masses. Prompt detection by tissue biopsy is crucial to differentiate these lesions from nasal polyps and more aggressive pathologies and avoid unnecessary surgery. Respiratory epithelial adenomatoid hamartomas (REAHs) are benign, glandular proliferations of the surface epithelium of the nasal cavity and paranasal sinuses, which were first reported by Wenig and Heffner in 1995 , 3. It iA retrospective case series of patients diagnosed with REAH at Austpath Laboratories was performed from 2014 to 2017. Patient demographics, clinical presentation and intraoperative findings were reported. In all cases, the mass was removed by transnasal endoscopic resection. Specimens were collected at the time of surgery, fixed in formalin and sent for histopathological analysis. The entire specimen was processed in all cases except one, in which representative sections were sampled. After routine dehydration and embedding, all tissue blocks were sectioned at 4 μm and stained with haematoxylin and eosin (H&E). The macroscopic and microscopic features were reported.Patient demographicsNine patients with REAH were reported. 78% were male (n = 7) and mean age was 59.4 ± 15.52 years. The presence of concurrent nasal polyps was evident in 67% (6/9) and as a solitary lesion in 33% (3/9). The nasal cavity was implicated in 89% (8/9) of cases, while the olfactory cleft was reported in one case. Notably, olfactory involvement occurred in the context of a solitary sinonasal mass. The macroscopic appearance was described as polypoid in seven cases and irregular in two. The size of the specimen ranged from 4 mm to 45 mm (average of 14.1 mm).Histopathological characteristicsIn most of the cases (seven of nine), the polypoid mucosal fragments showed prominent glandular proliferation. These glands were widely separated, small to medium sized, round to oval shaped and separated by stroma Figure . In two REAH remains an important differential in the context of sinonasal masses and can often be difficult to distinguish on clinical or radiological grounds alone. Furthermore, what was once thought to be an exceptionally rare entity is now considered to be more prevalent, especially in the context of nasal polyps. This may be due to an increased awareness of the condition by clinicians as more cases are being reported in the literature, but also a greater number of incidental findings on histopathological diagnosis.REAH, whether found in isolation or in association with nasal polyps, demonstrates typical histopathological characteristics . GlandulOther clinically important differential diagnoses for REAH include Schneiderian papillomas of the inverted type and low-grade adenocarcinomas. Macroscopically, these more aggressive lesions can resemble the benign hamartoma especially in its solitary form, and so histological characterisation is almost always required. Inverted papillomas exhibit invagination of hyperplastic squamous and/or respiratory epithelium surrounded by a thin basement membrane. The inverted growth of squamous epithelium is not found in REAH, yet this can be difficult to identify to the inexperienced pathologist.REAH occurs in adults with a strong male to female preponderance and typically affects those in their fifth and sixth decade of life. We report an average age of 59 years and males being affected in 80% of cases. This is in keeping with the original report of 31 patients by Wenig and Heffner who described a mean age of 58 years with 87% patients being male, as well as a larger study by Vira et al. who reported a mean age of 52 years with 57% being male . The majREAHs can present with similar signs and symptoms of the chronic inflammatory disease, which usually occur gradually and with a long duration, lasting from months to years. These include nasal obstruction, rhinorrhoea, facial pressure, headaches, and altered sense of smell . EndoscoThere is no clear etiologic factor in the development of REAH, however, the frequent association with nasal polyps suggests an inflammatory component . LorentzDespite this, reports of solitary REAHs do not exhibit a co-existing inflammatory process, and others theorise that perhaps inflammation occurs secondary to the growing mass , 11. FurTreatment of REAH is usually curative with endoscopic resection and recurrence following is extremely rare . DespiteREAH is a benign entity with hallmark histological features of glandular proliferation, surface epithelium that invaginates into the submucosa and oedematous intervening stroma. It is often found incidentally and given its low prevalence, can often be mistaken for other sinonasal masses seen clinically including inflammatory nasal polyps and true neoplasms like inverted papillomas and low-grade sinonasal adenocarcinomas. Surgeons predominantly rely on formal histological characterisation in order to avoid unnecessary or aggressive treatment.


Primary diaphragmatic lipoma (PDL) is a very rare condition. The aim of this paper is to report a case of diaphragmatic lipoma presenting as a case of diaphratmatic hernia with a brief literature review. A 73-year-old female presented with chronic dry cough for three month duration. The patient was stable, there was no significant finding on general, chest and abdominal examination. Chest-x-ray showed vague shadow above the left dome of the diaphragm. Computed tomography scan (CT scan) of the chest revealed a round mass with features consistent with either diaphragmatic hernia or malignancy. The patient underwent resection under general anesthesia and histopathological examination confirmed the diagnosis of PDL.Although PDL is a benign condition, in most of the time, it needs aggressive management because of the possibility of malignancy or other critical diseases. Among those odd occasions, the primary benign tumors most commonly detected are bronchogenic and mesothelial cysts, while metastatic benign tumors include endometriosis ,2. They Primary diaphragmatic lipomas are usually auxiliary findings. The first case of PDL was found in 1886 by Francis W. Clark in the postmortem examination of a 65-year-old female who died from the complication of intracapsular fracture of femur head . LipomasThe aim of this study is to report and discuss a case of diaphragmatic lipoma in line with SCARE guideline with a brief literature review .2A 73-year-old housewife female presented with chronic dry cough for three month duration associated with episodes of excessive salivation. She reported attacks of shortness of breath and cyanosis especially during sleep. She was a known case of controlled essential hypertension and she had history of a chest wall lesion before one year which was resected and later on she was diagnosed as case of basal cell carcinoma. She also had history of open cholecystectomy, caesarian section and laminectomy.3The patient was conscious, stable, there was no significant finding on general, chest and abdominal examination. Blood pressure: 160/80 mmHg, pulse rate 80 beats per minutes, respiratory rate 15 cycles per minute, temperature 37.3C.4complete blood counts, renal function tests, serum electrolyte, electrocardiography were normal. Chest-x-ray showed vague shadow above the left dome of the diaphragm . Broncho5The patient was prepared for general anesthesia. Under general anesthesia, in right lateral position, left side classical posterolateral incision was done. A soft mass was found attached to the diaphragm . It was 6The patient was healthy two months after the operation. All the symptoms were subsided.7Primary diaphragmatic tumor is an extremely rare tumor, being benign is even rarer. PDLs are ovoid, encapsulated, soft tumors, mostly occur in middle age obese patients with equal gender distribution . HoweverWilliam and Parson have classifies PDLs based on their anatomical location into: (1) Intrathoracic lipoma: situated completely within the thoracic cavity, attaching to the diaphragm in a sessile or pedunculated form, developing from subpleural mature fatty tissues. (2) Hourglass thoracic lipoma: those possessing an intrathoracic and an extrathoraic portion, developing from embryonally undifferentiated tissue, (a) cervicomediastinal: going from the mediastinum to the neck. (b) transmural: going through the chest wall, commonly an intercostal space, seldom through the sternum ,8,9. TheClinically, they may stay dormant with occasional symptomatic patients complaining of cough, dyspnea, chest pain, back and shoulder pain, hemoptysis, cardiac problems, obstructive sleep apnea, and even becoming fatal in case of diaphragmatic rupture ,7,10. AyNoninvasive imaging modalities such as chest-x-ray, ultrasound, CT scan or magnetic resonance imaging (MRI) are considered as gold standard for the diagnosis . PDLs arSurgical intervention is advocated for all cases as the probability of early stage liposarcoma cannot be eliminated . Open clIn conclusion, PDL is a very rare condition. Although it is a benign condition, in most of the time, it needs aggressive management because of the possibility of malignancy or other critical diseases.No source to be stated.Approval has been taken from Kscien centre.Consent has been taken from the patient and the family of the patient.Aram Baram: Surgeon performed the operation and follow up.Fahmi H. Kakamad: Writing the manuscript and follow up.Kizhan abdalla hama salih: Writing the manuscript, follow up.Rawand Abdulrahman Essa: Revising the manuscript, follow up of the patient.Dezhin Faeq Rashid: Writing the manuscript, follow up of the patient.Not applicable.Fahmi Hussein kakamad.Not commissioned, externally peer-reviewed.There is no conflict to be declared.


Desmoid tumors, also known as aggressive fibromatosis, are fibromuscular neoplasms that arise from mesenchymal cell lines. They may occur in almost all soft tissue compartments. Primary desmoids of the small bowel are rare but potentially serious tumors presenting unique challenges to the general surgeon. We present one case of a 59-year-old man presenting with three months of abdominal distension secondary to a small bowel desmoid. Computed tomography of the abdomen showed an 18-cm mass in the mid-abdomen without obvious vital structure encasement. Percutaneous biopsy of the mass indicated a desmoid tumor. The patient underwent a successful elective exploratory laparotomy with resection and primary enteric anastomosis. Final pathology revealed the mass to be a primary desmoid of the small bowel. His post-operative course was uneventful. At two years after surgery, he is symptom free, and there is no evidence of disease recurrence. Due to the rare nature of primary small bowel desmoids, there are few specific care pathways outlined. This is a challenging pathology to treat that often requires a multidisciplinary team of surgical and medical oncologists. Desmoid tumors, also known as aggressive fibromatosis, are fibromuscular neoplasms that arise from mesenchymal cell lines. Considered benign and generally not known to metastasize, desmoid tumors may be locally aggressive and cause organ compromise by mass effect. Desmoid tumors can be extra-abdominal, abdominal, or intra-abdominal . In the In 2013, a 59-year-old man presented to the general surgery clinic with a three-month history of gradually increasing abdominal distension associated with urinary urgency and right lower quadrant pain. He denied any weight loss, nausea, vomiting, or changes in bowel movements. Past medical history was significant for arthritis, hypertension, hypercholesterolemia, an appendectomy and colonoscopy with polypectomy in 2009. He reported no personal or family history of cancer or inflammatory bowel disease. His social history was unremarkable.On physical exam, his abdomen was distended with a firm, non-tender and palpable midline mass. Computed tomography (CT) of the abdomen and pelvis with intravenous contrast revealed an 18-cm solid mass in the mid abdomen  has outlined recommendations for the management of desmoids, although the recommendations are not specific to primary desmoid tumors of the small bowel . The recRadiation and systemic therapy are options for patients with unresectable disease, or in the setting of disease recurrence or progression. A review of 22 articles addressing intra- and extra-abdominal desmoids by Nuyttens et al. showed that surgery followed by radiation therapy or radiation therapy alone resulted in better local control than surgery alone . HoweverPrimary desmoid tumors of the small bowel may pose significant challenges to the general surgeon. Long-term recurrence for primary small bowel desmoids remains unclear. Elective surgery as patient condition allows is preferred, and the goal should be to achieve an R0 resection. These patients would likely benefit from having a multidisciplinary care team for treatment and monitoring. This case highlights a rare, treatable disease and the complexities of caring for patients with small bowel desmoids.


This study aims to present the feasibility of the open approach of hemilevator excision (HLE) as a promising alternative of the laparoscopic and/or robotic ones for the treatment of low rectal cancer extending to the ipsilateral puborectalis muscle.A 60-year-old male patient with a high-grade differentiated rectal adenocarcinoma at the right side of the lower rectum invading puborectalis muscle. The proposed operation consists of a combination of extralevator abdomino-perineal excision (ELAPE), intersphicteric resection (ISR), and low anterior resection (LAR) since it resects the ipsilateral to tumor levator ani muscle (LAM) from its attachment at the internal obturator fascia and the deep part of ipsilateral external anal sphincter (EAS), while the distal part of dissection is completed in the intersphincteric space taking out the internal anal sphincter (IAS). At the contralateral side of the tumor, the dissection plane follows the classic route of LAR.Pathology proved the oncologic adequacy of resection. MRI at the fourth postoperative week showed clearly the right aspect of anorectal junction free of tumor. Anorectal manometry revealed a fair anorectal function which is in accordance with the findings of clinical assessment of patient after restoring large bowel continuity .This is the first case of the open HLE that seems to be a good alternative compared to ELAPE or conventional APR, as it offers oncologic adequacy and a fair anorectal function. The treatment of cancer of the rectal lower third has been a challenging issue over time. Back in 1908, Ernest Miles first described the abdomino-perineal excision (APE) . HoweverA 60-year-old male patient was referred to our hospital with a high-grade differentiated rectal adenocarcinoma. The pelvic MRI revealed a tumor at the lower rectum  that invaded puborectalis muscle to a length of 9 mm on the right side. Moreover, the CT scan proved the absence of any distant metastasis. Given the tumor location and the absence of distant metastases, the patient went through manometric evaluation of anorectal function and clinical assessment with the Wexner scale score for incontinence . MRI at the fourth postoperative week showed clearly the right aspect of anorectal junction free of tumor and the absence of ipsilateral LAM Fig. .Fig. 3a In the earlier days of colorectal surgery for malignant tumors of the lower third of rectum, the operation of choice was the abdomino-perineal resection (APR) in which the sigmoid, the rectum, and the anus were excised leaving the levator ani muscle complex intact in both sides. In this way, the specimen resembles an hourglass due to the characteristic “waist” in the middle . HoweverThis is the first attempt at Greece to perform a technique which targets the saving of anal sphincter for very low rectal cancers with extension to the puborectalis muscle. This is the first procedure with removal of puborectalis muscle and partial excision of external sphincter with preservation of anal function. This innovative procedure requires full knowledge of pelvic anatomy. The surgical team must have experience to the standard TME. This procedure is the hope for a life without colostomy for patients with these tumors. Undoubtedly, a larger number of cases is demanded to draw firm conclusions since we have to take into account that anatomic characteristics such as gender, body mass index, etc. might affect the feasibility of the procedure.


Internal hernias are uncommon and are defined by the protrusion of a viscus through intraperitoneal defects. Left paraduodenal hernias (LPDH) are the most common type of congenital internal hernia (CIH).We report a clinical case of a patient with a small bowel obstruction (SBO) due to a LPDH.An elderly patient, with negative surgical history, presented to the emergency room with abdominal pain and vomiting. Clinical and radiologic investigations were consistent with SBO due to an internal hernia. During laparotomy, a large LPDH containing dilated small bowel loops was identified. The hernia contents were reduced and the opening was closed with non-absorbable sutures. The post-operative course was uneventful without signs of recurrence at follow up.LPDH result from absence of retroperitoneal fixation of the descending colon mesentery. Usually, patients are asymptomatic and LPDH are incidental findings detected on imaging and/or during laparotomy. However, LPDH may lead to acute SBO therefore a high index of clinical suspicion and preoperative imaging is crucial to make an early diagnosis.CIH is a rare condition due to embryologic developmental abnormalities. Their diagnosis is based on pathognomonic findings on computed tomography scanner (CTscan). Surgical treatment is the mainstay treatment. Delay diagnosis of strangulated CIH is associated with significant morbidity andmortality. It can be natural and anatomical such as the Winslow foramen or abnormal resulting from embryological abnormalities such as gut malrotation or absence of retroperitoneal attachments  ,2.CIH are responsible for 0.6–5.8% of the etiologies of small bowel obstruction (SBO) . Left paWe report a clinical case of an elderly patient with SBO due to a large LPDH and a brief literature review about the management of SBO secondary to LPDH. This work has been reported in line with the SCARE criteria .2A 76-year-old male patient presented to our emergency department with a 24 h history of gradual onset left upper quadrant abdominal pain associated with nausea, vomiting, anorexia, and obstipation. Patient had no medical history of abdominal surgery. On presentation, he was afebrile, dehydrated with normal heart rate and blood pressure. On clinical examination his abdomen was distended and tender upon palpation of left upper quadrant without guarding or rebound tenderness. White blood cell count and CRP were 10,500/mm³  and 10 mg/L (<10) respectively. He had a slight renal insufficiency with a creatinine level of 2.6 mg/dl (0.72–1.17).The rest of the blood tests  were unremarkable. Abdominal X-rays study showed a cluster of small bowel loops in left upper quadrant with multiple air-fluid levels. Abdominal computed tomography scanner (CT scan) confirmed the diagnosis of SBO with transition zone left to the Treitz ligament A and B aDue to the high risk of strangulation, and the presence of symptoms, the patient was consented for exploratory laparotomy. At exploration, a huge hernia sac  arising 3LPDH are three times more common than the right paraduodenal hernias with an autopsy incidence of 2% ,7. LPHD Male are affected 2–3 times more than females . AlthougIn most of reported cases, the diagnosis of LPDH is made during laparotomy . HoweverIn our patient the suspicion of LPDH on CT scan led to the decision of urgent surgery as in case of acute presentations related to hernia strangulation, the reported mortality varies from 20 to 50% .A laparo4LPDH has to be considered among the differential diagnosis of small bowel obstruction in a patient without abdominal surgical history. In such a case, urgent surgery is warranted due to the high risk of mortality in cases of hernia strangulation. Detailed knowledge of the anatomy, etiology and vascular landmarks allow the surgeons to accurately manage this type of hernia.We have no conflict of interest to declare.The authors have no funding source to disclose for this work.The submitted article is a case report, ethical approval has been exempted by our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Youssef Sleiman, Alaa El-Kheir and Omar Hamdach: paper concept, design, data collection and interpretation. Youssef Sleiman and Alaa El-Kheir: writing the manuscript. Layla Ismail and Melody El-Khoury: reviewing and editing. Mustafa Allouch was the operating surgeon and responsible for drafting and revising the article content and for the final approval of the manuscript prior to submission.Not applicable.Dr Mustafa AllouchNini Hospital, El-Maarad Street, Tripoli, Lebanon.allouchmustafa@gmail.com.Tel: 009613684906.Not commissioned, externally peer reviewed.


Pseudo-ascites is a very rare condition in children and remains a challenging diagnosis. Targeted imaging may be helpful, but a high index of clinical suspicion is often necessary to guide the investigations, as pseudo-ascites may efficiently mimic true ascites. To date, still many cases of pseudo-ascites suffer diagnostic and therapeutic delay, and some are only diagnosed during surgical exploration. We report the case of a patient with a late laparoscopic diagnosis of pseudo-ascites. We retrospectively review our patient’s imaging findings and suggest new characteristic features which may help differentiate pseudo-ascites from true ascites.A 7-month-old infant was referred for a progressive abdominal distention. Physical examination and initial ultra-sonographic findings evoked free ascites. An extensive diagnostic workup was then performed and was negative for hepatic, renal, cardiac, intestinal, pancreatic, inflammatory or infectious diseases, malignancy and congenital metabolic disorders. Pseudo-ascites was evoked and dedicated ultra-sonographic and magnetic resonance studies were repeated but could not confirm this diagnosis. Symptomatic diuretic treatment with spironolactone and furosemide was then started. A temporary and limited effect was noted but, with time, repeated paracenteses were necessary as the abdominal distention progressed causing discomfort and breathing difficulty. Last, because the patient’s quality of life deteriorated, a peritoneal-venous shunting was proposed; as the operation started with a diagnostic laparoscopy, a benign giant cystic mesenteric lymphangioma was identified and totally excised. The resolution of symptoms was immediate and the patient remained symptom-free throughout the subsequent observation period that lasted more than 1 year.Increased awareness about pseudo-ascites is necessary, as the diagnosis is often overlooked, and treatment delayed. Targeted imaging may be helpful, as some specific, although not pathognomonic, features exist which may aid in the diagnosis. Pseudo-ascites (PA) is an uncommon cause of abdominal distention mimicking ascites. It can present both in adult and pediatric patients. Its etiology comprises benign and, very rarely, malignant cystic masses that can be mis-diagnosed for ascites when they are very large. The most common entities are cystic lymphangiomas, mesenteric and omental cysts, renal cysts, cystadenomas and ovarian cysts, mesothelial cysts, enteric cysts, mature cystic teratomas, and pancreatic or traumatic cysts. Sometimes a PA can be secondary to an infection, as for example of hydatid or mycobacterial origin. Because the diagnosis of a PA is usually not evoked primarily, and because a positive diagnosis is difficult, most PA patients experience a significant delay in the identification of their condition, with a variable impairment of their quality of life until an adequate treatment  , 2. We rPIEZO1 mutation; the analysis of PIEZO1 gene was however found negative. As an interferon-gamma test (QuantiFERON®) was positive, peritoneal tuberculosis was suspected, but the chest x-ray and the Mantoux test of the patient and his parents were negative. Gram and acid-fast stain and culture of three gastric aspirates resulted negative. Furthermore, the repeated interferon gamma test was negative and atypical mycobacterial infections were also excluded. A MRI of the abdomen only confirmed an abundant collection of liquid in the abdomen, with centralization of the bowel loops and a normal aspect of all abdominal organs  showed the presence of fluid in the Morison’s pouch, in the left upper abdominal quadrant, and Douglas space; the liquid appeared free in the abdomen in the absence of definite septation nor a multi-cystic appearance thus confirming the clinical impression of ascites. There were no abdominal masses or abdominal organ abnormalities. A comprehensive workup excluded hepatic, renal, cardiac, intestinal, pancreatic, inflammatory or infectious diseases, malignancy, and congenital metabolic diseases. The child had had in the past a mild pleuro-pericardic effusion during a febrile illness and a transient mild hyperkaliemia, evoking a possible stomatocytosis due to ans Fig. . There wPA is defined as an abdominal distention mimicking ascites. When PA is caused by large abdominal cysts, it is difficult to distinguish from simple ascites because of the presence of an ultra-thin-wall and large liquid collection. It is a very rare entity and thus the literature on this argument is scarce: it mostly comprises case reports and small case series. Vrettos and colleagues recently reviewed this topic emphasizing the challenge and the difficulty in positively identifying a PA . Their rAlthough PA is often amenable to a simple and radical treatment, it remains a challenging condition to identify and it is typically associated with unnecessary delays before a diagnosis and cure are proposed. This retrospective case description should increase the awareness of clinicians for that condition. It also suggests that the absence of liquid between the liver and the diaphragm is a specific, although not pathognomonic, element at imaging that may help to differentiate PA from free ascites.


Catamenial pneumothorax (CP) is a rare and usually miss diagnosed condition that is often characterized by non- specific respiratory or gynecological symptoms. A high index of suspicion is warranted for early diagnosis and management.We present a case of 34 year old female who presented with shortness of breath and dyspnea.The radiological diagnosis was pneumothorax with further history, it was apparent that is was a case of primary infertility secondary to possible pelvic endometriosis. She was treated as a case of bilateral catamenial hemopneumothorax after confirming the diagnosis through surgical exploration & repair of right hemidiaphragm.This case demonstrate the extensive bilateral catamenial hemopnemothorax which is limitedly described in the literature index of suspicion & early diagnosis and management would ensure multiple admission & recurrence. Endomet2A 34 year old female who is not known to have any medical illnesses, presented to our emergency room with progressive shortness of breath for several days. She denies any fever, cough, or symptoms of upper respiratory tract infection. There was no chest pain, palpitations or lower limb edema. Her history revealed that she had the same episode years back and diagnosed as a case of right and left primary spontaneous pneumothorax respectively. She was underwent VATS (Video-Assisted Thorocoscopic Surgery) on the left side and tube thoracostomy drainage on the right side. Her medical history demonstrated primary infertility for which she was treated by hormonal therapy but was not successful. The suspicion of pelvic endometriosis was lost in mind but the patient did not complete the treatment. On examination, she was hemodynamically stable her chest examination revealed decreased air entry on both sides with hyper resonant percussion note. Her laboratory findings were within normal expected a picture of microcyctic and hypochromic anemia. Her initial chest x-ray showed bilateral lucencies and reticular patterns a. Comput3Thoracic endometriosis syndrome (TET) remains a commonly missed, or underdiagnosed disease . Increas4TES is becoming more and more common, with increasing awareness. Catamenial and/or thoracic endometriosis-related pneumothorax represents a complex puzzle, and finding some pieces of the puzzle should suffice for high suspicion on its diagnosis. This case demonstrates the variable presentations of TES and the optimal management.The following manuscript did not involve any funding resource for any part of the process.Research approval has been attained by the hospital body ethics committee, furthermore consent for writing up the case report while maintaining anonymity was taken from the patient.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.Writing the paper: Dr. Saja Al-Aqeel.Data Collection: Dr. Saja Al-Aqeel.Data Analysis: Dr. Saja Al-Aqeel, Dr. Yasser Al-Jehani.Literature Research: Dr. Saja Al-Aqeel.Manuscript Editing and Review: Dr. Yasser Al-Jehani, Dr. Mona Al-Muhaish.Manuscript Finalization: Dr. Saja Al-Aqeel, Dr. Yasser Al-Jehani.N/A.Dr. Saja Al-Aqeel.Not commissioned, externally peer-reviewed.The following is a disclosure that the following case report holds no financial or otherwise personal relationship with other people or organizations that may influence our work. No conflict of interest is present.