Irreducible umbilical swelling in infants is considered a surgical emergency because a delay in surgical intervention for an incarcerated umbilical hernia can lead to bowel ischemia and necrosis. We report two patients who presented to a pediatric emergency department with history and symptoms of irreducible umbilical mass suggestive of umbilical hernia. Point-of-care ultrasound was used at the bedside to demonstrate the presence of urachal cyst remnants and accurately guided the care of these children. Irreducible umbilical swelling in infants is considered a surgical emergency because a delay in surgical intervention for an incarcerated umbilical hernia can lead to bowel ischemia and necrosis.A previously healthy 10-month-old female presented to our emergency department (ED) with a two-day history of multiple episodes of non-bilious vomiting and abdominal distension. One week prior to presentation, the parents had noticed an irreducible umbilical mass. There was no history of diarrhea or fever. On examination she was alert, her heart rate was 108 beats per minute, blood pressure was 84/50 millimeters of mercury (mmHg), capillary refill was less than two seconds, and there were no signs of dehydration. Her abdomen was distended but soft and bowel sounds were present. An irreducible tense umbilical mass of 3×3 centimeters (cm) was noted. The skin was normal around the umbilicus, but appeared shiny over the mass. Her cardiovascular, respiratory and central nervous system examination was unremarkable.An initial diagnosis of incarcerated umbilical hernia was considered. The pediatric emergency medicine (PEM) fellow performed a POCUS using linear transducer (14-5MHz), which showed a well-circumscribed hypoechoic structure suggestive of a fluid-filled sac. The sac did not communicate with the intra-abdominal cavity, and there was no evidence of bowel loops or peritoneum in the sac . A diagnA two-year-old male presented to the ED with redness and a prominent protrusion in the umbilical area for two days. There was no fever, vomiting, abdominal pain or discharge from the umbilicus. He had a recent hospitalization for urinary tract infection requiring intravenous antibiotics. On examination he was alert, his heart rate was 96 beats per minute, blood pressure was 104/72 millimeters of mercury (mmHg) and capillary refill was less than three seconds. The abdomen was soft and non-tender, with no guarding or rebound tenderness. An umbilical mass of 2×2 cm was noted, and the overlying skin was erythematous and tender. The skin around the mass was not erythematous or indurated. The genitourinary examination showed normal, bilaterally descended testes and no inguinal hernia.The PEM fellow performed a POCUS using linear transducer (14-5MHz), which revealed a protruding hypoechoic structure suggestive of a fluid-filled sac that did not communicate with the intra-abdominal cavity. There were no bowel loops within the sac and there was no cobblestoning of the overlying skin . A probaWhat do we already know about this clinical entity?Irreducible umbilical swelling in infants is a surgical emergency because a delay in surgical intervention for an incarcerated umbilical hernia can lead to bowel ischemia and necrosis.What makes this presentation of disease reportable?We present the first report of point-of-care ultrasound being used in the diagnostic algorithm for irreducible umbilical swelling in infants.What is the major learning point?Urachal cyst remnant is a rare but important differential diagnosis for irreducible umbilical swelling in infants.How might this improve emergency medicine practice?Bedside ultrasound is a simple and useful clinical adjunct that can be used to facilitate a quick and early diagnosis of urachal cyst remnants in infants and children.Median umbilical ligament, or urachus, is a midline tubular structure that extends upward from the anterior dome of the bladder toward the umbilicus. It is a remnant of two embryonic structures: cloaca, which is the cephalic extension of the urogenital sinus, and allantois, which is derived from yolk sac.7POCUS evaluation of the umbilical mass is ideally done using a high-frequency linear probe to visualize superficial structures; however, a phased array or curvilinear probe can also be used. The umbilical mass must be visualized in both transverse and longitudinal planes. Use of adjuncts such as color and power Doppler can provide vital information about the blood flow into the umbilical area and surrounding structures. The skin around the umbilicus should be scanned to look for cobblestoning. This finding, in conjunction with clinical signs such as skin erythema and tenderness, may suggest cellulitis.The sonographic appearance of urachal cyst is a fluid-filled anechoic structure, which lies between the skin and anterior abdominal wall in the midline of the abdomen, below the umbilicus. No bowel content or peristalsis is visualized.We present the first reports of point-of-care ultrasound application by a pediatric emergency physician to identify urachal remnants in children. Ultrasonography can readily identify urachal cyst greater than a few millimeters in size.


A 74-year-old man was examined for a mass in the left upper eyelid. It was inconspicuous in inspection. There was no visual restriction, however a feeling of friction on the superior orbit during lid movement. Through eyelid crease lid incision, a solitary lesion appeared in the preaponeurotic space that orginated from the upper tarsal plate. Excisional biopsy revealed adipose proliferation with patch form vessels. This case represents the second reported angiolipoma of the eyelid in English literature. Angiolipomas are common variants of lipomatous tumors. They most commonly occur on the extremities and trunk of children and adolescents. It is rarely encountered in the orbital region. We present a rare case of angiolipoma within the eyelid with associated friction in the glide zone.A 74-year-old man was referred to the opthalmology clinic with a history of a mass in the left upper eyelid that had been present for four years. Visual acuity was 7/10 for the right eye and 6/10 for the left eye, anterior segment examination revealed grade 2 nuclear cataract for the right eye and grade 3 nuclear cataract for the left eye. Motility was bilateral normal with no diplopia. Levator functions were bilateral normal, except there was a minimal mechanical ptosis for the left eye. There was also a subcutaneous mass on the left forearm. Systemic check-up relevead no other illness or malignancy. On clinical examination, there was a subcutaneous, firm and round mass located on the central left upper eyelid, which was non-tender to palpation. It was inconspicuous on inspection. There was no eyelid movement restriction but a feeling of friction on the superior orbit during lid movement. Ultrasonography showed a homogeneous echogenic and well defined mass in the anterior orbit. No internal vascularity was seen. An excisional biopsy was taken through the crease of the upper eyelid under local anesthesia. The lesion was 9x7x7 mm in diameter and located 15 mm superior to the eyelid margine and located under the orbicularis muscle. During the removal operation, it was noted that the lesion was stuck to the tarsal border from its base. The mass was removed completely and its location was cauterized while preserving the underlying tarsal plate Figure 1 . HistoloAngiolipoma accounts for 6–17% of all lipomas. It rarely occurs in the head and neck region  while orSeveral hypotheses have been proposed for the cause of this lesion: embryonic sequestration of multipotential cells, fatty metamorphosis of a central hemangioma, and vascular proliferation of congenital lipoma. Mast cell-derived vascular endothelial growth factor (VEGF) was suggested as a possible reason for increased vascularity in this particular tumor . Angiolipoma characteristically occurs as an encapsulated mass of mature adipose tissue containing clusters of vascular network that was first described by Bowen in 1912. These tumors are frequently tender and occur on the trunk, extremities, and especially forearm of young men. Angiolipomas are classified as infiltrating and non-infiltrating based on the presence of a complete capsule. The infiltrating type is usually poorly encapsulated and has a high recurrence rate after surgical removal .There have been a few reports of lipomatous variants involving the eyelids: dermolipomas, myolipomas, spindle cell lipomas, and others. The nasopalpebral lipoma-coloboma syndrome associated eye abnormalities and palpebral lipoma are rare congenital abnormalities . The upper eyelid consists of two layers; the anterior skin/orbicularis oculi layer and posterior layers of the levator aponeurosis, Müller’s muscle, and the tarsal plate. The glide zone is in the middle of the two layers consisting of the preaponeurotic fat and all potential space. When the levator contracts, the tarsal plate glides up under the skin and orbicularis, therefore the glide zone acts like a friction-free layer .Our patient was experiencing discomfort when looking straight ahead from downgaze. The mass expanded up to the tarsal plate so it was touching the superior orbit. The case presented here is the second reported angiolipoma that appears as an eyelid mass. A histologic variant of lipoma should be considered in diagnosis, if it occurs in unusual locations.The authors declare that they have no competing interests.


Rhabdoid meningioma is an infrequent variant of meningioma, introduced for the first time in the 2000 World Health Organization’s classification of tumors of the nervous system. Owing to its aggressive clinical course and high proliferative index, it has been classified as a grade III neoplasm. We describe a fifty-year-old male with headache, weakness of limbs, and altered sensorium. CT showed hetero-dense enhancing mass lesions in both right and left parietal areas raising suspicion of high grade glioma. Histopathologic and immunohistochemical examination revealed a tumor with features of rhabdoid meningioma. A review of literature did not reveal any bilateral occurrence of this tumor. Meningiomas are tumors of meningothelial origin having a wide range of histological appearances. They are most commonly benign and slow growing in nature. Some subtypes however are recognized to display aggressive behavior including atypical, clear cell, chordoid meningiomas (WHO grade II) and papillary and anaplastic variants belonging to WHO grade III , 2]. Re. Re2]. RA 50-year-old male presented with headache since the past two months. He also complained of weakness in both upper and lower limbs and altered sensorium for the past fifteen days. On physical examination, the patient was conscious with a GCS of E4M6V4. The power was reduced on the left side (3/5), but maintained on the right side (5/5). Computed tomography (CT) revealed well defined hetero-dense masses measuring 5x4 cm and 2x2 cm in the right and the left parietal region respectively with surrounding edema and mass effect Figure 1 . A diagnMeningiomas are neoplasms thought to derive from arachnoidal cap cells in the meningeal coverings of the spinal cord and brain. Meningiomas are generally benign, slow growing tumors which produce neurological symptoms and signs due to their compression of adjacent structures . The incth to 7th decades with a marked female preponderance (11:4). The more aggressive subtypes usually present in younger age groups [The most commonly affected age groups are the 5nderance 1:4. The The term rhabdoid in this tumor refers to the classical morphology of the tumor cell which bears close resemblance to a rhabdomyoblast without true skeletal muscle differentiation . NumerouMultiplicity in meningiomas attracts a lot of interest because of its relative rarity, unclear aetiology, and the problems related to proper management strategy. Majority of multiple meningiomas 80–90%) are benign and classified as WHO grade I. Anaplastic or malignant meningiomas (WHO grade III) are the rarest (1–3%) 0–90% are. The occRhabdoid meningiomas are associated with rapid growth, brain invasion, and frequent recurrences . They alThe authors declare that they have no competing interests.


A solitary fibrous tumour (SFT) is an unusual neoplasm typically found in soft tissues. Although SFTs can arise in the bones, they very rarely arise in the vertebral arch. Here, we describe a case of a SFT that arose in the vertebral arch of the first lumbar (L1) spinal vertebrae and mimicked osteosarcoma.NAB2-STAT6 fusion gene, thus confirming our final diagnosis of malignant SFT. The patient died of disease progression 8 years after the first surgery; however, there was no evidence of local recurrence.A 49-year-old woman presented with a 2-month history of lower back pain and a lumbar region mass. Magnetic resonance imaging demonstrated a heterogeneously enhanced mass in the L1 vertebral arch. The patient received neoadjuvant chemotherapy, followed by a surgical procedure comprising an anterior spinal fusion and en bloc resection. Histologically, our initial diagnosis was osteosarcoma. The postoperative course was uneventful, and the patient received adjuvant chemotherapy. However, the tumour metastasised to the lung 5 years after the first surgery, and a second surgery was performed for lung tumour resection. The histology of the metastatic lung tumour appeared similar to that of the malignant SFT, and the specimen from the first surgery was re-examined. Immunohistochemically, the tumour was positive for STAT6. Reverse transcription-polymerase chain reaction revealed a Malignant SFT in the vertebral arch is extremely rare and very difficult to distinguish histologically an osteoid from lace-like collagen. STAT6 immunostaining is useful for distinguishing malignant SFTs from other neoplasms. Although it is difficult to completely resect a SFT arising from the spine, we demonstrated the feasibility of an en bloc resection of spinal tumours arising from posterior elements, without local recurrence. A solitary fibrous tumour (SFT) is a rare type of spindle cell tumour that was first described to originate from the pleura . AlthougA 49-year-old woman was referred to our hospital with a 2-month history of lower back pain and a mass in her lumbar region. The patient provided written informed consent for the use of her case data. Physical examination revealed a tender, immobile mass in her lumbar region, but no weakness or sensory deficits. Computed tomography (CT) revealed a 3 × 3 × 4 cm mass exhibiting inhomogeneous contrast enhancement in the vertebral arch of the L1 vertebra Fig.  and heteA marginal resection and anterior spinal fusion were performed from the 12th thoracic (T12) to the third lumbar (L3) vertebra. During surgery, the patient was placed in the right lateral position. The extrapleural retroperitoneal approach was used, and the lateral aspect of the vertebral body was exposed from T12 to L3. Anterior vertebral screws were placed in the vertebral bodies from T12 to L3, and the disks and end-plates were removed. Subsequently, iliac bone and rib allografts were implanted, and rods were inserted using screws. After wound closure, the patient was placed in the prone position.A lens-shaped incision that included the biopsy scar was made with a 2-cm margin from the tumour and deepened carefully to maintain a wide curative margin. The bilateral pars interarticularis of T12, tips of the transverse processes of L1 and L2, facet joint of L2/3, and vertebral arch of L3 were exposed. The bilateral pars interarticularis of T12 were cut using a high-speed drill, and a L2/3 facetectomy was performed. Elastic T-saw guide tubes were inserted into the spinal canal from the outside of the L1/2 neural foramen and was advanced cranially (to cut the L1 pedicle) or caudally (to cut the L2 pedicle). The T-saw was subsequently passed through the guide tube and successfully placed around the bilateral L1 and L2 pedicles , was F-NAB2 ex6 forward-2, AGCAGACACTGATGGACGAG, and the reverse primer, which targeted exon 16 or 17 of STAT6 (5′-3′), was STAT6 ex 17 reverse, TGGGCTTCTTGGGATAGAGA. These primers yielded PCR-amplified DNA fragments with approximate lengths of 219 bp . The immunohistochemical analysis of paraffin-embedded sections prepared from this specimen revealed a diffuse positive STAT6 staining in the tumour cell nuclei Fig. . RT-PCR d method . The for bp Fig. , upper.  16 Fig. , lower. Systemic chemotherapy with gemcitabine and paclitaxel was initiated. However, CT scans taken 2 months after the second surgery revealed a metastatic lesion in the pancreas Fig. . AlthougSFT, a rare neoplasm, was first described in 1931 by Klemperer and Rabin as a spindle cell tumour that originated from the pleura –4. SpinaOn MRI scans, most SFTs appear hypointense or isointense relative to the muscle on T1-weighted images and have a heterogeneously hyperintense tumour component on T2-weighted images . AdditioHistologically, SFTs comprise spindle cells in a “patternless pattern” characterised by a combination of alternating hypocellular and hypercellular areas interspersed with thick bands of hyalinised collagen . HoweverNAB2 and STAT6 on chromosome 12 in the majority of SFTs [NAB2 exon 6-STAT6 exon 16 fusion led us to confirm a diagnosis of malignant SFT.Immunohistochemical examination is useful for distinguishing SFTs from other neoplasms. Most SFTs exhibit positive staining for CD34, bcl-2, and CD99, but negative staining for αSMA, desmin, and S-100 protein. However, these immunohistochemical markers are nonspecific and can be detected in a variety of other neoplasms [ of SFTs . Moreove of SFTs . Therefo of SFTs . In thisNAB2-exon 6-STAT6 exon 16/17 fusions more frequently exhibited cellular histologic features associated with more aggressive behaviour [Although most SFTs have benign features, these tumours may recur or metastasise in the absence of any predictive morphological features . As a reehaviour . The preIn this case, we performed an interbody fusion using anterior, rather than posterior, instrumentation because posterior reconstruction after extensive soft tissue removal could increase the risk of postoperative infection. Fortunately, the patient’s postoperative course was uneventful, and she was immediately able to receive adjuvant chemotherapy after surgery.We found the T-saw to be useful for cutting pedicles. The exact locations of these pedicles were difficult to identify because the posterior elements of the vertebrae were almost completely covered with extensive soft tissue, which had to be resected en bloc. It might have been dangerous to cut the pedicles from the lateral side to the medial side using an osteotome in this case, given the risk of neural damage. Although additional time was needed to set the T-saw around the pedicles, the process of cutting the pedicle from the medial wall to the lateral wall was safer.Some authors have reported the surgical resection of SFTs arising from the spine , 6, 8. BWe have reported a malignant case of a SFT that occurred in the L1 vertebral arch. Malignant SFTs rarely occur in vertebral arches and are very difficult to diagnose accurately using histologic techniques. Immunohistochemical STAT6 staining is very useful for distinguishing SFTs from other neoplasms, such as osteosarcoma. Although it is difficult to completely resect a SFT arising from the spine, we have demonstrated the feasibility of an en bloc approach to the removal of primary spinal tumours arising from posterior elements without local recurrence.


Primary leiomyosarcoma (LMS) of the vein is a rare tumor that arises from the smooth muscle cells of the vessel wall and has an extremely poor prognosis. This tumor can occur in vessels such as the inferior vena cava, great saphenous vein, femoral vein, iliac vein, popliteal vein, and renal vein; the inferior vena cava is the most common site. LMS of the femoral vein can result in edema and pain in the lower extremity; therefore, it is not easy to be differentiated from deep vein thrombosis (DVT). Moreover, virtually no studies have described the ultrasonographic features of LMS of the vein in detail.We present a case of a 55-year-old woman with LMS of the left femoral vein that was misdiagnosed as having deep vein thrombosis (DVT) on initial ultrasonographic examination. The patient began to experience edema and pain in her left leg seven months previously. She was diagnosed as having DVT on initial ultrasonographic examination, but the DVT treatment that she had received for 7 months failed to improve the status of her left lower limb.She subsequently underwent re-examination by means of a multimodal ultrasonographic imaging approach , which confirmed a diagnosis of LMS.This patient was treated successfully with surgery.This case demonstrates that use of multiple ultrasonographic imaging techniques can be helpful to diagnose LMS accurately. Detection of vasculature in a dilated vein filled with a heterogeneous hypoechoic substance on ultrasonography is a sign of a tumor.The pitfall of misdiagnosing this tumor as DVT is a useful reminder. This tumor can occur in vessels such as the inferior vena cava, great saphenous vein, femoral vein, iliac vein, popliteal vein, and renal vein; the inferior vena cava is the most common site, according to the literature.–8 LMS of the femoral vein can result in edema and pain in the lower extremity, and consequently, is not easy to be differentiated from deep vein thrombosis (DVT). Moreover, the ultrasonographic features of LMS of vein has been reported in some cases, but virtually no studies have described the ultrasonographic features of LMS of the vein in detail.The majority of leiomyosarcomas (LMS) originate in the muscle layers of the gastrointestinal tract or uterus. Primary LMS of the vein is a rare tumor that arises from the smooth muscle cells of the vessel wall. Al-Saif et alIn this case, we used a multimodal ultrasonographic imaging approach  and found LMS of the femoral vein, which had been misdiagnosed as DVT. The pitfall of misdiagnosing this tumor as DVT is a useful reminder.2The patient signed the necessary documents to consent to the use of her data for teaching and publication.33.1A 55-year-old woman was admitted to the Vascular Surgery Department of our hospital for ultrasonographic examination of suspected LMS in the left common femoral vein. Seven months previously, the patient had begun to experience edema and pain in the left leg, and underwent a rapid ultrasonographic evaluation in the emergency department of our hospital. Based on the ultrasonography, thrombus in the left common femoral vein and superficial femoral vein was diagnosed. The patient was administered anticoagulation therapy, with no improvement of the status of the lower limb. Before anticoagulation therapy, coagulation factors, fibrinogen level, and C-reactive protein (CRP) level were normal. During anticoagulation therapy, prothrombin time was 20.4 s  and International Normalized Ratio was 1.8 s , while other laboratory data, including fibrinogen level, thrombin time, activated partial thrombin time, and CRP level, were normal. She underwent a repeat ultrasonographic examination after 7 months, which confirmed that a tumor, rather than a blood clot, had involved the left external iliac vein, common femoral vein, deep femoral vein, and superficial femoral vein. Physical examination revealed a mass with a diameter of approximately 2 cm in the left inguinal region, which could not be pushed, mild cyanosis, and swelling of the left leg.3.2The first ultrasonographic examination  performed 7 months previously in the emergency department had revealed dilation of the common femoral vein , as well as a hypoechoic mass in the lumens of the left external iliac vein, common femoral vein, deep femoral vein, and superficial femoral vein. Color Doppler flow imaging revealed no color flow signal in the lumen of the common femoral vein. Thus, the patient was diagnosed as having DVT.In the second examination, we used a multimodal ultrasonographic imaging approach . High-resolution gray-scale images further revealed a dilation of the common femoral vein , as well as a hypoechoic mass in the lumens of the left external iliac vein, common femoral vein, deep femoral vein, and superficial femoral vein  for confirmation, which revealed a partial enlargement of the left external iliac vein and common femoral vein due to a heterogeneous mass of soft tissue density filling their lumens. The mass showed an obvious heterogeneous enhancement in the arterial and venous phases Fig. A and B.3.4During surgery, we found a mass extending from the left external iliac vein to the common femoral vein bifurcation, causing an obvious enlargement of the lumens of the involved veins Fig. A. When t4 LMS of the inferior vena cava are usually >10 cm long, hypoechoic, and heterogeneous; a cystic component also can be found, which is estimated to be related to tumor necrosis. However, no cystic component was found in our patient.LMS of the vein usually causes DVT-like symptoms, and thus, can be misdiagnosed as having DVT. In China and many other countries, ultrasonography is the preferred method for diagnosis of DVT because it is a convenient, fast, noninvasive, cost-effective, and real-time imaging technique. However, sometimes, routine ultrasonographic examination of DVT may not be performed correctly when the venous lumen cannot be fully compressed despite firm compression with the transducer probe. One ultrasonographic feature of acute venous thrombosis is increased venous diameter due to a hypoechoic substance filling the lumen. In the present case, repeat ultrasonography 7 months later showed a significantly increased venous diameter due to the initially detected hypoechoic mass that had later increased in size. In chronic venous thrombosis, however, the venous lumen usually gets smaller with time. Thus, the above unusual finding led us to question our earlier diagnosis, and we took a multimodal ultrasonographic imaging approach to make a more precise diagnosis. According to Bousquet et al, Newly formed arteries are a key finding to differentiate between vascular tumor and thrombus. Color Doppler flow imaging is a ready-to-use technique during basic ultrasonographic examination of a thrombus. In fact, correct setting of Doppler parameters can detect intratumoral color Doppler signals and prompt contrast-enhanced imaging techniques, such as CEUS and CECT for confirmation. Due to the incorrect setting of Doppler parameters , the first ultrasonographic examination in the emergency department failed to detect intratumoral color Doppler signals and led to misdiagnosis as DVT. To better display blood flow in the tumor, we used a higher-frequency probe for scanning . Color Doppler flow imaging in the superficial condition revealed rich color spots and linear blood flow signals in the mass, which are consistent with the findings reported by Perisano et al. Pulsed-wave Doppler imaging revealed the low- and high-resistance arterial flow, PSV: 14.0 cm/s, EDV: 7.02 cm/s, RI: 0.50  are not typical signs of LMS. According to Hübsch et al,,16,17Both CEUS and CECT can make a correct diagnosis of LMS in a vein. Regular high-resolution B-mode ultrasonography and color Doppler flow imaging may be superior to CT in showing local details of peripheral blood vessels and revealing hemodynamic information, but tend to have difficulties in showing the deeper blood vessels, such as the external iliac vein and inferior vena cava. Since CEUS is based on B-mode ultrasonography, it is subject to its limitations. For example, the image quality of CEUS is influenced by obesity and intestinal gas. On the other hand, CT, especially CECT, can provide comprehensive information, such as location, size, and extension of the tumor, as well as the relationship of the tumor with the surrounding tissues and organs, without being interfered by obesity and intestinal gas. Therefore, CECT is better than CEUS for examination of tumors in the external iliac vein. In our case, CECT was used to confirm the findings of CEUS. Both CEUS and CECT revealed the venous enlargement due to a heterogeneous mass of soft tissue density filling the lumen, and the obvious heterogeneous enhancement probably due to tumor heterogeneous perfusion and hemorrhage or necrosis, which are consistent with the findings reported in the literature.In order to correctly diagnose cases like this in the clinical setting, ultrasound-guided tissue biopsy also can be used. However, ultrasound-guided biopsy is an invasive examination. Taking into account that abundant image inspection was conducted , we disregarded ultrasound-guided biopsy and performed surgical resection. However, the detailed descriptions of multimodal ultrasonographic features, CT discovery, surgical findings, and pathological findings and any images of the multimodal ultrasonography, CT, surgery, and pathology have never been reported.A brief description of the general clinical presentations and mutimodal ultrasonographic features of this case has been included in a recent paper.5In summary, our multimodal ultrasonographic imaging approach enabled preoperative diagnosis of LMS. The key point in our case was careful observation by an alert sonographer when suspecting the presence of a tumor in the left external iliac vein and femoral vein. In contrast, in patients with suspected acute thrombosis, various ultrasonographic techniques should be used to carefully look for signs of tumor vasculature. The pitfall of misdiagnosing LMS as DVT is a useful reminder.www.editage.com) for English language editing.The authors thank Editage (


To report a case of metastatic hepatocholangiocarcinoma to the vitreous and retina.A 70-year-old male, who was recently diagnosed with hepatocholangiocarcinoma, was complaining of floaters in his right eye over the past 5 months and was referred to the Liverpool Ocular Oncology Centre. On presentation, his visual acuity in the right eye was 6/24. Fundus exam revealed a whitish, unilateral, full-thickness retinal lesion at the inferotemporal arcade of his right eye, with vitreous infiltration and subretinal fluid. The patient underwent 25G pars plana vitrectomy with biopsy, resection of the lesion and intravitreal bevacizumab injection. Histopathology testing of the surgical specimens confirmed the diagnosis of metastatic carcinoma to the eye. Two months postoperatively his visual acuity had improved to 6/7.5 and there was no sign of active disease in his right eye, while 9 months postoperatively his visual acuity decreased to 6/9.5 due to developing nuclear sclerotic cataract in his right eye.The current report presents the first case of a hepatocholangiocarcinoma metastasis to the vitreous and retina. Hepatocellularcarcinoma (HCC) and cholangiocellularcarcinoma (CCC) within the same liver, is designated as hepatocholangiocarcinoma (HCC/CCC) . Uveal mA 70-year-old male was referred to Liverpool Ocular Oncology Centre (LOOC), complaining of floaters in his right eye (RE) over the past 5 months. One month before presentation to LOOC, the patient presented to Oncology Department with abdominal pain, lack of appetite and weight loss. The patient was diagnosed by Medical Oncologists with HCC/CCC with multiple liver metastases. The diagnosis of HCC/CCC was made via endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) with 19G needle of the primary tumour which sent for histology and confirmed the diagnosis. Computed tomography (CT) scan confirmed the presence of liver metastases. The staging of the tumour was T3N1M1 and/or stage IV B (liver metastases).2 on days 1 and 8 along with cisplatin 70 mg/m2 on day 1, after intraocular metastatic disease was diagnosed.On presentation to LOOC, best corrected visual acuity (BCVA) was 6/24 in RE and 6/4.8 in left eye. Fundus examination of his RE showed a single whitish elevated lesion 3–4 DD in size at the infero-temporal arcade associated with vitreous infiltration and intra- and sub-retinal fluid. Fig.  The patiOne month postoperatively, his BCVA has improved to 6/9.5 in his RE and fundoscopy revealed peripheral retinal haemorrhage and subretinal haemorrhage near the resolving metastatic lesion. Two months postoperatively the BCVA had improved to 6/7.5 and there was no sign of active disease in his RE Fig. . Four moThe patient underwent in total 8 cycles of palliative chemotherapy with gemcitabine along with cisplatin approximately every 4 weeks but unfortunately succumbed to widespread metastatic disease 5 weeks after completion of last chemo cycle and one year after the initial diagnosis of the primary disease.HCC/CCC has emerged as a distinct subtype; it represents less than 1% of primary liver cancers . There aMetastatic lesions are the most common intraocular malignancies. The majority of intraocular metastases affect the choroid, while the ciliary body, the iris, the retina and the vitreous are less frequently affected. The current case illustrates the first case of a rare site of metastasis to the vitreous and retina for HCC/CCC. Breast and lung cancer most commonly metastasises to the uvea , 3. PatiAs the patient presented with a recently diagnosed systemic malignancy and some primary tumours tend to metastasize to the retina and vitreous, the suspected diagnosis was that of retinal and vitreous metastatic lesion. The differential diagnosis included fungal endophthalmitis an infectious retinitis of unknown origin. The biopsy was performed to establish the suspected diagnosis of an intraocular metastasis against the background of the unusual location of the lesion , 3 as thIn conclusion, the current report presents the first case of unusual HCC/CCC metastasis to the vitreous and retina. A retinal and vitreous biopsy was required to establish the diagnosis, while the therapeutic options for this case included local treatment for the intraocular metastasis and systemic chemotherapy for the primary lesion and its metastatic disease.


Duodenal obstruction occurs mainly due to physical lesions such as duodenal ulcers or tumors. Obstruction due to bezoars is rare. We describe an extremely rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy for early gastric cancer.Diospyros kaki); therefore, he was diagnosed with a diospyrobezoar. His postoperative progress was good and without complications. He left the hospital 10 days after surgery. EGD performed 4 weeks after surgery revealed no abnormal duodenal findings.A 73-year-old man who underwent laparoscopic distal gastrectomy for early gastric cancer 15 months before admission experienced abdominal distension and occasional vomiting. The symptoms worsened and ingestion became difficult; therefore, he was admitted to our department. Computed tomography (CT) performed on admission revealed a solid mass in the third portion of the duodenum and dilatation of the oral side of the duodenum and remnant stomach. Esophagogastroduodenoscopy (EGD) revealed a bezoar deep in the third portion of the duodenum. We could neither remove nor crush the bezoar. At midnight on the day of EGD, he experienced sudden abdominal pain. Repeat CT revealed that the bezoar had vanished from the duodenum and was observed in the ileum. Moreover, small bowel dilatation was observed on the oral side of the bezoar. Although CT showed neither free air nor ascites, laboratory data showed the increase of leukocyte (8400/μL) and C-reactive protein (18.1 mg/dL), and abdominal pain was severe. Emergency surgery was performed because conservative treatment was considered ineffective. We tried advancing the bezoar into the colon, but the ileum was too narrow; therefore, we incised the ileum and removed the bezoar. The bezoar was ocher, elastic, and hard, and its cross-section was uniform and orange. The postsurgical interview revealed that the patient loved eating Japanese persimmons (We describe a rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy with Billroth I reconstruction for early gastric cancer. Duodenal obstruction occurs mainly due to physical lesions such as duodenal ulcers or tumors . ReportsA 73-year-old man who had undergone laparoscopic distal gastrectomy with Billroth I reconstruction for early gastric cancer 15 months before experiencing abdominal distension and occasional vomiting was admitted to our hospital. The patient had undergone follow-up computed tomography (CT) and esophagogastroduodenoscopy (EGD) for 1 year after surgery (2 months before admission), during which time no abnormal findings, including the previously observed dilatation of the bile and pancreatic ducts, were found.Diospyros kaki) and seemed to eat 30-40 persimmons in one season; therefore, a diospyrobezoar was diagnosed. His postoperative progress was good and without complications. He left the hospital 10 days after surgery. EGD performed 4 weeks after surgery revealed no abnormal duodenal findings.Symptoms worsened and ingestion became difficult. On admission, blood tests showed a slightly inflammatory reaction, and CT revealed a solid mass in the third portion of the duodenum and dilatation of the oral side of the duodenum and remnant stomach Fig. . EGD revDiospyros kaki) [shibuol, which is a type of tannin [shibuol comes in contact with gastric juice, polymerization of the persimmon fiber occurs and contributes to the formation of diospyrobezoars [Bezoars are solid masses of ingested foreign materials found in the lumen of the gastrointestinal tract and are named according to their composition, such as phytobezoars (food fibers), trichobezoars (hair), and pharmacobezoars (drugs) . The dioos kaki) . Persimmf tannin . When shobezoars .Moreover, gastrectomy is associated with the formation of diospyrobezoars . GastrecWe searched for articles with ‘duodenal obstruction’ and ‘bezoar’ as keywords in PubMed, 93 articles were hit. Filtered 93 articles by the publication date (in this decade) and the language (English), 17 articles remained. In addition, excluded those of animals, duodenal obstruction due to trauma, other than duodenal obstruction and reviews, 10 articles remained –11. In tIn our case, bezoar was located in the third portion of the duopdenum. Leanness due to gastrectomy causes superior mesenteric artery (SMA) syndrome, which involves compression of the third portion of the duodenum between the aorta and the SMA. The diospyrobezoar formed in the remnant stomach or in the duodenum, suggesting that it was caught in the third portion of the duodenum and suggesting SMA syndrome. Among previous 11 cases, only a case was similar to our case . We searAs a treatment for trichobezoar, surgical methods, endoscopic methods  and dissolution therapy by Coca-Cola are known. Dissolution therapy by Coca-Cola was introduced by Ladas et al. in 2002 . Recent We describe an extremely rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy with Billroth I reconstruction for early gastric cancer.


Sclerosing pneumocytoma is a rare lung tumor that is usually recognized as a solitary nodule in the lung. Surgical removal is recommended; however, its clinical diagnosis is still an issue because it is difficult to differentiate from lung adenocarcinomas using a tiny sample obtained from biopsy.We report a case of pulmonary sclerosing pneumocytoma located in the upper lobe of the right lung of a 34-year-old woman, which was diagnosed before surgery by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).A 3-cm irregular mass was detected by chest X-ray without any symptoms. She was referred to our hospital after being followed for 10 years in her previous clinic. During this follow-up period, the tumor had grown to 5 cm. We performed the EBUS-TBNA for the diagnosis. The histological findings obtained by EBUS-TBNA consisted of alveolar type 2-like cells that were positive for napsin A and round cells that were positive for vimentin. Based on these immunostaining results, we successfully diagnosed sclerosing pneumocytoma before surgery. Right upper lobectomy was performed, and the pathological diagnosis of the surgical specimen was also confirmed as sclerosing pneumocytoma.We herein report a case of sclerosing pneumocytoma, which was clinically diagnosed by EBUS-TBNA and resected surgically. Sclerosing pneumocytoma is a rare and slow-growing benign tumor of the lung, and clinical diagnosis through biopsy is often difficult to differentiate from lung adenocarcinomas or carcinoids –3. PreopEBUS-TBNA is a minimally invasive method of hilar/mediastinal biopsy from parabronchial lesions that is mainly used for the diagnosis or nodal staging of lung cancer. EBUS-TBNA shows high accuracy and a low false-negative rate  and is aHowever, there are no reports which have so far described the efficacy of EBUS-TBNA in the diagnosis of sclerosing pneumocytoma. We experienced a case of sclerosing pneumocytoma that was diagnosed by preoperative EBUS-TBNA.The patient was a 34-year-old asymptomatic woman who visited our hospital due to an abnormal nodule of the right lung that was detected on a chest X-ray and who had been followed up for 10 years in a previous clinic. Computerized tomography (CT) revealed that the tumor had grown from 3.0 to 5.0 cm during the 10-year follow-up period and that it was well enhanced and adjacent to the right pulmonary artery  features show extreme variation . ClinicaSurgical resection is recommended for this disease, and several reports showed that similar surgical outcomes are obtained by lobectomy and sublobar resection . We usuaWe were able to make an accurate preoperative diagnosis of sclerosing pneumocytoma based on the findings of a specimen obtained by EBUS-TBNA.


Heterotopic pancreas is a relatively uncommon congenital anomaly, defined as pancreatic tissue in ectopic sites without an anatomic and vascular continuity with the main body of the pancreas. We report the case of a 58-year-old woman who was admitted to the hospital with the clinical suspicion of a mild, acute pancreatitis. Computed tomography, magnetic resonance imaging, transabdominal ultrasound, and endoscopic ultrasound revealed a normal orthotopic pancreas and the suspicion of a large heterotopic pancreas in the small bowel mesentery with signs of acute inflammation. The diagnosis of mesenteric heterotopic pancreatitis was preoperatively confirmed by endoscopic ultrasound-guided fine-needle aspiration and consequently histologically established after surgical resection. Heterotopic pancreas, also referred to as ectopic pancreas, aberrant pancreas, or choristoma, is defined as the presence of pancreatic tissue in ectopic sites which lacks an anatomic and vascular continuity with the main body of the orthotopic pancreas. Although it is the most common heterotopia within the gastrointestinal system, it still concerns a relatively uncommon entity with prevalence at autopsy studies ranging from 0.6 to 13.7% [∗109/L) and a normal C-reactive protein (CRP) level . Serum amylase was increased . Liver function tests results were within normal ranges. Besides a significantly increased urine amylase , urinalysis was normal. Additionally, abdominal ultrasound was performed but the diagnostic value was limited because of body habitus. The ultrasound examination revealed a small amount of fluid around the liver. There was no evidence of cholelithiasis. The pancreas was not conclusively visualized. With the suspicion of a mild, acute pancreatitis, based on both clinical and laboratory findings, the patient was admitted to the hospital for conservative treatment and both biochemical and radiologic follow-up.A 58-year-old woman presented to the Emergency Room with an acute, 4-hour history of increasing continuous abdominal pain. The pain was severe and associated with nausea and vomiting. She reported not having a medical history, no history of a similar episode of abdominal pain, no alcohol consumption, and no smoking. Physical examination revealed generalized abdominal pain. The vital signs were stable. Early laboratory values included a normal white blood cell count  was performed on the third day after onset.CT revealed a normal morphology and homogenous enhancement of the pancreas, with only a small amount of fluid located around the tail of the gland . The preTo confirm the hypothesis of heterotopic pancreatitis, an additional targeted ultrasound and magnetic resonance imaging (MRI) of the abdomen were performed. Ultrasound depicted a nonspecific hypoechoic region in the mesentery with a central, lobulated, unsharp delineated, more hyperechoic soft tissue mass . MRI witIn order to rule out a malignancy and to confirm the diagnosis of heterotopic pancreatic tissue, the gastroenterologist performed an endoscopic ultrasound (EUS) with additional fine-needle aspiration (FNA). EUS performed from the horizontal part of duodenum showed a hypoechogenic mass of 3 × 4 cm with indistinct delineation and poor vascularisation with adjacent enlarged lymph nodes and inflammatory changes Figures . EndoscoAfter one week of conservative treatment, acute clinical findings resolved and laboratory results improved, consequently the patient was discharged from the hospital. A follow-up CT scan of the abdomen, six weeks after admission, revealed the soft tissue mass with substantial regression of inflammatory changes. There were no complications such as cyst formation or necrosis. The orthotopic pancreas was unremarkable .To conclusively validate the earlier clinical hypothesis and to further analyze the lymph nodes that had increased in size, an additional EUS was executed. EUS performed from the horizontal part of the duodenum depicted the pancreas-like mass with apparent ductal structures . The masThe diagnostic findings and the possibility of a resection were discussed with the patient. Given the risk of recurrent episodes of pancreatitis and consequently more challenging surgery and possible malignant degeneration –4, the mGenerally considered a developmental anomaly, heterotopic pancreas is defined as anatomically separated pancreatic tissue from the main gland, without vascular or ductal continuity. Most cases of heterotopic pancreas are found in the upper gastrointestinal tract with 70–87% of cases affecting the stomach, duodenum, and jejunum in mostly submucosal localization , 5. LessThe exact embryologic basis of heterotopic pancreas is unknown, but there are three apprehended theories. The most widely held theory is the misplacement theory, which states that deposits of pancreatic tissue are “dropped” into the developing gastrointestinal system , 8, 9. TIt has been reported that the enhancement pattern of heterotopic pancreas varies depending on the microscopic composition and therefore can differ from the main pancreas. This can cause an unreliable differentiation from other homogenous enhancing tumours, such as gastrointestinal stromal tumour (GIST), carcinoid, lymphoma, or metastasis , 11. NevMost heterotopic pancreatic lesions exist solitary, in contrast with both the jejunal and mesenteric manifestation in our case, and measure smaller than 3.0 cm. A heterotopic mesenteric manifestation has a mean long axis diameter of 4.4 cm. It typically presents as an elongated lobulated lesion (long- to short-diameter ratio of 3.0) showing a broad base on the jejunal mesenteric side, tapering as it extends centrally into the mesentery , 11. To Characteristically, the majority of patients are asymptomatic, with lesions being incidentally detected at surgery, endoscopy, or autopsy. Complications of heterotopic pancreas may or may not be related to pathologic conditions of the pancreas itself. Those related might present with inflammation, (pseudo)cyst formation, endocrine (dys)function, or malignant degeneration , 13–17. Heterotopic pancreatitis is a recognized complication that is usually only detected at microscopy and is rarely diagnosed clinically or radiologically, especially in cases of submucosal manifestations. Usually, the elevation of serum amylase and lipase is modest due to the small volume of pancreatic tissue in the heterotopic tissue . In our In case of an asymptomatic patient and histopathologically confirmed diagnosis, a conservative management might be applicable. However, in case of a symptomatic patient or if accurate differentiation from other benign or malignant aetiologies cannot be accurately made, curative resection of the heterotopic pancreas is usually considered . The patHeterotopic pancreas is a relatively uncommon congenital anomaly. Most cases concerning solitary lesions were found in the upper gastrointestinal tract in submucosal localization. Though the majority of patients are asymptomatic, patients may present with clinically significant pathology such as inflammation or malignant degeneration, identical to the normal, orthotopic pancreas. We report a case of symptomatic, heterotopic pancreatitis in a patient with heterotopic pancreas tissue in the jejunal serosa and the jejunal mesentery. The clinical diagnosis was made using imaging modalities and cytopathological analysis, that is, ultrasound, CT, MRI, and EUS combined with FNA. Cytopathological examination preoperatively confirmed the diagnosis which is only limitedly reported in current literature. Subsequently it was histopathologically confirmed after complete resection.


Neuroendocrine tumors (NETs), also known as carcinoid tumors of the extrahepatic biliary tree, are extremely rare malignancies and account for 0.2% to 2% of all carcinoids of the gastrointestinal tract. The most common sites include NET in the common bile duct (CBD), followed by the perihilar region, cystic duct, and common hepatic duct (CHD). A review of the literature showed only eight cases of NETs of the cystic duct and we, hereby, present the ninth case of NET of the cystic duct in a 50-year-old woman. This was discovered incidentally after she underwent a laparoscopic cholecystectomy for her symptomatic gallbladder stones. The etiology is not known but the NETs are thought to arise from argentaffin cells (Kulchitsky cells) in the gastrointestinal tract or respiratory tract. It is possible that the rarity of these in this region may be explained by the very limited number of Kulchitsky cells there. Most of the patients are clinically asymptomatic, and the diagnosis is mostly made during surgery performed for other indications. Therefore, early recognition should be sought by differentiating the primary duct carcinoma of the bile or the cystic duct, if suspected or shown on the imaging studies because of the different therapeutic options and prognosis. Adenocarcinoma is the most common neoplasm >80% arising from the epithelium of the biliary tree. Other tumor types found in the extrahepatic bile ducts include adenoma, leiomyoma, lipoma, paraganglioma, and granular cell tumor. Neuroendocrine tumors (NETs), also called carcinoid tumors of the extrahepatic bile ducts, are extremely rare, accounting for 0.2% to 2% of all the carcinoids of the gastrointestinal tract . The estDue to a small number of reported cases, the natural history and pathologic and other characteristics of these neoplasms are not well understood at present, but the oncology community has adopted the World Health Organization (WHO) staging system for NETs in this location as well, which is based on tumor size, histological differentiation, Ki-67 immunostaining, invasion of adjacent tissues, and vascular and perineural invasion . This stHowever, the literature review indicated that a majority of the cases of carcinoid tumors of the extrahepatic biliary tract were usually of low malignant potential and had a favorable overall prognosis following aggressive surgery. Because of the rarity of cystic duct NET, we report here a case of a carcinoid tumor of the cystic duct and a review of the literature.A 50-year-old African American woman presented to our office for a follow-up visit for a NET of the cystic duct, which was an incidental finding post-cholecystectomy. She previously visited the emergency department (ED) with the chief complaint of right upper quadrant (RUQ) pain that was sudden in onset, and she rated it eight on a scale of one to 10. It was also associated with nausea, vomiting, and a low-grade fever. Her ultrasound revealed multiple gallstones with mild inflammatory changes in the gallbladder. After a pre-operative course of antibiotics, she underwent elective cholecystectomy, and the specimen was sent to the pathology department for assessment. It revealed a microscopic focus of NET in the resected margin of the cystic duct with perineural infiltration and raised the suspicion for lymphatic vessel invasion too  was 29.6. She was vitally stable. The results of her liver function tests (LFTs) and tumor markers are summarized below  scan showed normal liver contours with no masses or hepatomegaly and a surgically absent gallbladder. No intra- or extra-hepatic duct dilatation was appreciated. The rest of the imaging, including the bone scan, was normal with no evidence of metastatic pockets. Her screening colonoscopy was normal too.The departments of surgery and oncology were involved in the case and decided to closely monitor the patient with three monthly follow-ups since she was asymptomatic and the initial laboratory data and imaging did not reveal anything alarming. She was followed regularly with serial chromogranin A, gastrin, cancer antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), serotonin, pancreatic polypeptide, and vasoactive intestinal peptide (VIP) levels, respectively.The patient is currently stable since the past two years from the time of surgery and remains free of cancer.Neuroendocrine tumors (carcinoid) are thought to arise from the argentaffin cells (Kulchitsky cells) that are present throughout the gastrointestinal tract but exist in scarcity in the extrahepatic biliary tree. NETs of the biliary tract are extremely rare. The first case of a NET of the gallbladder was reported by Lubarsch in 1888 . In 1961The rare incidence of NETs in the cystic duct can be explained by the very limited number of the embryonal neural crest cells in this region . It is uDespite the limited number of cases reported, these NETs have been well described in the literature, ranging from benign and well-differentiated tumors to malignant neoplasms with erratic growth and aggressive behavior. Though secondary to a small number of reported cases, the natural history and pathologic, immunohistochemical, and structural features of these neoplasms are not well understood at present, and the majority of the cases reported have been described to be well-differentiated (low grade) -2,4,6. OThe review of the previously published medical literature also revealed that most of the patients were clinically asymptomatic, similar to our patient. This is problematic because this delays the diagnosis as the majority of the cases are diagnosed following surgery for other medical conditions. However, some reported cases did have symptoms such as painless jaundice or abdominal (RUQ) pain, possibly due to the increased size of the tumor and/or impingement of the ducts -6. NonetThere are various diagnostic methods used to establish the diagnosis and staging of NETs, including CT scans, magnetic resonance imaging (MRI), immunohistostaining with tumor markers, endoscopic ultrasound (EUS), percutaneous cytology, somatostatin receptor scintigraphy, and positron emission tomography (PET) ,8. The dSurgical resection is the treatment of choice for the cystic duct NETs that offers a potential cure -10. PatiNETs of the extrahepatic biliary tree, and especially of the cystic duct, are very rare tumors with only a handful of cases reported in the literature. It is prudent to differentiate them from the non-neuroendocrine tumors of the same region because the therapeutic options and prognoses differ in both instances. It is also important to categorize the tumors according to the WHO classification once the diagnosis is made, either pre-operatively or post-operatively, as the decision of surgery versus medical or palliative management is based upon the category in which the tumor falls. Our patient had a well-differentiated NET of the cystic duct, which was found following cholecystectomy, and she was asymptomatic with normal radiological imaging and tumor markers. Since her tumor was localized and small, we, therefore, devised regular follow-ups with serial tests to monitor the tumor’s hibernating state, catch its possible progression or metastasis early, and save the patient from unnecessary invasive surgeries.


Thymic epidermoid cysts are an extremely rare entity. These arise from epidermal cells that migrate to the thymus. The radiologic diagnosis of this rare lesion is challenging. We describe a case of an otherwise healthy 35-year-old woman who presented with an acute onset of chest pain and shortness of breath. She was found to have an anterior mediastinal mass. The imaging findings were, however, not characteristic for any single diagnostic entity. Since the imaging was inconclusive, surgical resection was performed for definitive diagnosis. The mass was found to be a thymic epidermoid cyst. This case underlines the significance for radiologists to be aware that epidermoid cysts can occur in the thymus and should be considered in the differential diagnosis for a heterogeneous anterior mediastinal mass. Thymic epidermoid cysts are extremely rare with only three cases described in literature. These are benign and carry an overall good prognosis. However, the location is atypical and imaging findings are nonspecific. Despite their benign nature, surgical resection is required to exclude malignancy and attain a definitive tissue diagnosis.A 35-year-old lady presented with chest pain and shortness of breath, one week after undergoing a C-section. She was evaluated with a chest computed tomography angiography (CTA) to evaluate possible pulmonary emboli. The chest CTA was negative for pulmonary emboli but incidentally demonstrated a homogenous 5 cm mass in the anterior mediastinum Figures  and 2. TCT-guided needle biopsy was performed for definitive diagnosis. This showed benign squamous and fibroconnective tissue and was inconclusive. She subsequently underwent a right robotic assisted thoracoscopy for resection of the mass. A 9.5 cm × 7.0 cm × 3.0 cm soft, round mass with a red, glistening capsule was resected following careful dissection from the adhering mediastinal structures. The surgical specimen was submitted for pathological analysis . The finThymic epidermoid cysts are an extremely rare entity. To the best of our knowledge, this is the 4th reported case. Rare cases of epidermoid cysts have been reported within the spleen, kidney, and the GI and GU tracts .The exact etiology of thymic epidermoid cysts remains unknown. Developmentally, the thymus forms primarily from epithelial cells derived from the endoderm with a mesenchymal thymic remnant. Epidermoid cysts are sequestration cysts that form by proliferation of epidermal cells that arise from the ectoderm within an unusual location within the thymus . AcquireThere has been a case report of an acquired, posttraumatic thymic epidermoid cyst. This was thought to result from the introduction of epidermoid cells into the thymus following trauma . EpidermThe clinical presentation is variable. In the past, epidermoid cysts in the thymus have been diagnosed in asymptotic patients. They have also been found during the workup for chest pain, dyspnea, fever, or hemoptysis. A history of chest trauma or recent surgery may be present. There was no history of trauma in our patient. She first noticed her symptoms towards the end of pregnancy.The imaging findings are nonspecific, which may be misleading for the radiologists. The differential diagnosis includes thymic hyperplasia, teratoma, thymic neoplasm, or lymphoma. Due to its rarity, an epidermoid cyst of the thymus is not typically part of the differential diagnosis . In our Pathology showed that the cystic mass was attached to the normal thymus. The epithelial lining of the cyst consisted of stratified squamous epithelium with abundant keratin debris present within the cyst. No other epithelial or mesenchymal components were identified. These findings were consistent with a thymic epidermoid cyst.Epidermoid cysts can occur anywhere in the body. However, the thymus is a very unusual location. This is only the fourth reported case, to the best of our knowledge. These may be found incidentally on asymptomatic patients or on routine workup for chest pain and shortness of breath. A history of trauma or surgery may be associated. Imaging findings are nonspecific. That being said, surgical resection may eventually be necessary to reach a definitive diagnosis. While extremely rare, this entity should be considered in the radiologic differential diagnostic of a heterogeneous anterior mediastinal mass.


Mullerian-type ciliated cysts are uncommon lesions usually found in the lower extremities and perineal region of young females. They have however been reported in males and in other anatomic sites. The cyst lining is typically positive for estrogen receptor (ER), progesterone receptor (PR), PAX-8, and WT1 immunohistochemical stains. This staining pattern has led to the notion that these cysts are of Müllerian origin. The vast majority of cases are located in the dermis where the preferred nomenclature is cutaneous ciliated cyst (CCC). We report a case of Müllerian-type ciliated cyst in the thigh of a 16-year-old girl. Unlike most of the cases reported in the English literature, this cyst was not centered in the dermis. Only a few other cases of Müllerian-type ciliated cysts with no cutaneous connection have been reported. We propose the term ectopic Müllerian cyst for this rare subset of lesions that are not skin based as is the current case.  Cutaneous ciliated cysts (CCC) also known as cutaneous Mullerian cysts are rare lesions which mostly occur in the lower extremities of females . Up to 2A 16-year-old girl presented with a solitary, 2 cm, freely mobile mass in the soft tissue of the right thigh. The cyst had been present for at least 3 years. According to the patient, the mass has waxed and waned but was for the most part increasing in size. There is no associated rubor, calor, pain, tenderness, skin changes, or drainage. She denied fever, anorexia, asthenia, and weight loss. She has no significant past medical or surgical history. There is no history of pregnancy or preceding trauma. At surgery, the mass was situated in the subcutaneous soft tissue. It was incised revealing its cystic nature. The cystic fluid was expressed and the mass was completely excised and sent to the pathology department for further evaluation. simple ciliated cuboidal to columnar epithelium with no significant cytologic atypia (Surgical pathology received a 2.5 cm tan-brown collapsed unilocular cyst. Skin was not identified in the specimen on gross inspection. The cyst wall measured 0.1 cm in thickness. The inner lining was tan, smooth, and glistening. Representative sections were submitted for microscopic examination. On low magnification, sections showed a cystic lesion whose fibrocollagenous wall was thrown into multiple folds forming finger-like projections focally . A thoroc atypia . Pseudosc atypia , inset. c atypia . The latCutaneous ciliated cyst is an uncommon lesion with only 60 cases reported in the English literature between 1890 and 2015 . The entMullerian cysts may present as solitary unilocular or multilocular lesions. The ciliated epithelial lining is reminiscent fallopian tube epithelium ; howeverDespite the various theories proposed with respect to their origin, the Mullerian heterotopia theory is supported by this striking resemblance to fallopian tube epithelium and by the consistent nuclear positivity for antibodies to the steroid receptors for estrogen and progesterone . PAX-8, Of note however, similar cysts have been reported in male patients , 9, 10 aIn 1997 Sidoni and Bucciarelli reported a case of a ciliated cyst in the skin of the perineum of a 60-year-old man, the origin of which they suggested was primitive caudal gut. They hypothesized that the cyst was derived from embryonic remnants of the cloacal membrane . Cysts lIt may be that these differing theories are substantial and that ciliated cysts of the skin and soft tissue form part of a heterogenous group of lesions developing from different histologic and embryonic structures. Hung et al. have proposed that the term cutaneous ciliated cyst be abandoned for “cutaneous Mullerian cysts” for those cysts which show features of Mullerian origin. They also propose the use of cutaneous ciliated eccrine cysts for the other group of cysts which occur in males and appear to be derived from ciliated metaplasia occurring in eccrine cells. Bivin Jr. et al. compared eccrine sweat glands with CCC histologically, immunohistochemically, and ultrastructurally and found them “completely unrelated” .In this instance, the cyst was located in the upper thigh and showed strong staining not only for ER and PR but also for PAX-8 and WT1. These findings strongly support a Mullerian origin as mentioned by previous authors. Interestingly, unlike most cases of cutaneous ciliated cysts reported in the literature, our case showed no definitive evidence of cutaneous connection. A previously reported case with no attachment to skin was found in a postmenopausal woman on hormone replacement therapy with estrogen and gestagen . We sugg


Iron deficiency anemia (IDA) and abdominal pain are commonly seen in a pediatric emergency department (8 and 18% incidence respectively in our center). They are manifestations of a wide variety of diseases ranging from benign to immediately life-threatening. Trichobezoar is an under-diagnosed entity that has to be considered in children and adolescents, expecially female, suffering from trichotillomania (compulsion to pull hair) and trichophagy . When undiagnosed, gastric bezoars may cause gastric ulceration, perforation, haemorrhage and obstruction.To underline the importance of including this pathology in the differential diagnosis of IDA and abdominal pain, we present the case of a 14 year-old girl with a huge trichobezoar which completely filled the stomach and extended into the small bowel. Since trichobezoar has an extension to the small bowel, it is classified as Rapunzel syndrome. As the bezoar couldn’t be removed by endoscopy, the girl underwent surgical intervention. The patient passed through a gradual re-feeding, with iron and vitamins supplementation, and through a psychiatric counselling.The Rapunzel syndrome is a rare entity that may be complicated by life-threatening events. A prompt diagnosis and an appropriate therapy can reduce comorbidities. Gradual re-feeding with supplementation of micronutrients allows adequate catch-up weight with normalization of haematochemical nutritional parameters. Since many of these patients suffer from psychiatric pathology such as PICA with emotional problems and mental retardation, psychological/psychiatric counselling plays an important role in order to prevent bezoar recurrence. Bezoars are collection of non-digestible foreign bodies such as hair that usually accumulate in the gastrointestinal tract. They are commonly found in domestic animals, whereas in humans it is a rare condition mainly seen in female adolescents . In the s until it becomes too large, because of the high capacity of the stomach.Trichobezoars are more commonly found in children and adolescents with normal gastrointestinal function and usually result from an underlying behavioral disorder known as “Rapunzel syndrome”  which isSymptoms of the obstruction are recurrent abdominal pain, nausea, vomiting, anorexia, weight loss and malabsorption of trace elements. When undiagnosed, gastric bezoars may also cause severe anemia either due to malabsorption or gastrointestinal bleeding .Methods of removal of small gastric bezoars are minimally invasive, such as endoscopy but large trichobezoars, which often are non-fragmentable, can only be removed by open surgical intervention.Our report describes a trichobezoar, classified as Rapunzel syndrome, in a 14 year-old girl and highlights the salient features of diagnosis and treatment.A 14 years old girl was brought to our pediatric emergency unit because of severe hypocromic microcytic anemia detected by her primary care physician who had required blood tests to investigate the cause of reported asthenia and weight loss. Her mother reported that the patient had experienced early satiety and abdominal pain for several months. No history of fever or trauma as well as no dysuria, gross hematuria or recent travel abroad. Reported regular menstrual cycles until 2 months before admission.With regards to the past medical history, a neurosurgical intervention for cranial meningocele of the bregmatic region at the age of 6 years and laparoscopic cholecystectomy for gallstones at the age of 13 years have been reported. At the time of cholecystectomy, hemoglobin was normal as well as hemoglobin electrophoresis. Initially, parents denied that their daughter had any history of eating disorder such as PICA, though alopecia was reported.At physical examination: anorexic habitus, pulse rate of 88 beats/min, respiratory rate of 28/min, very pale skin and mucosae, no evident bleeding nor icterus. Her abdomen was rigid under palpation with a non- compressible mass in the left upper quadrant.Laboratory tests, including erythrocyte morphology, confirmed a severe IDA, with normal Serum electrolytes, amylase, thyroid and liver function tests and vitamin B6, B12 and folate at the lower range of norm. Fecal occult blood test was positive.Abdominal ultrasound (US) showed perihepatic free fluid and mild splenomegaly (10.5 cm diameter) and computed tomography (CT) scan reported severe gastric dilatation due to organic matter accumulation. The mass completely filled the gastric fundus and antrum and extended into duodenum. Also, small bowel dilatation and air-fluid levels were present . Thus, the patient was referred for surgical evaluation. The patient underwent surgical intervention by means of a median sovraumbilical laparotomy and anterior gastrotomy; a 1360 g trichobezoar was extracted  and sent to histological examination which concluded for gastric trichobezoar, with vegetable fibers and amorphous matter.After appropriate transfusion of erythrocytes and plasma, endoscopist evaluation was requested. In the light of the large size of the mass, it was thought that endoscopy could likely fail to remove the mass Fig. . Thus, tThe post-operative course was characterized by the onset of fever. A CT scan of the abdomen and thorax revealed perisplenic and pleural effusion with pulmonary consolidation which required a broad-spectrum antibiotic therapy and the abdominal placement of a drainage tube which was removed 6 days later. Feeding was gradually reintroduced, first by means of total parenteral nutrition and then orally with supplementation of iron, vitamin B complex, folate and other micronutrients. During this period, the patient was carefully monitored for post surgical complications.At the time of hospital discharge, blood values were normalized and we observed an initial catch-up weight; pulmonary and abdominal US didn’t show any residual free fluid collection.The patient underwent both psychiatric and psychological evaluations before discharge. Both concluded for PICA disorder, on the basis of history of reported and chronic ingestion of small stones which started during primary school attendance and subsequent hair ingestion that the patient was pleased to eat because she found them to be tasty. According to DSM-V  , PICA isTrichobezoar, an under-diagnosed entity, has to be considered in the differential diagnosis of IDA and abdominal pain in pediatric emergency department (8 and 18% incidence respectively in our center), especially if an history of PICA is reported. Key point of our case report is that the prompt diagnosis of trichobezoar in an adolescent presenting with severe IDA, abdominal pain and trace elements deficiency leads to immediate and appropriate treatment. Our case also stresses the importance of gradual re-feeding and close clinical monitoring in order to assess complications related to surgery such as surgical site infection and leakage . An impoMost patients with trichobezoars suffer from psychiatric disorders including trichotillomania and trichophagia. It is estimated that 1 out of 2000 children worldwide suffer from trichotillomania and that 30% of them will also suffer from trichophagia . Only 1%Patients may be asymptomatic for years. Symptoms develop as the trichobezoar enlarges and begins to cause obstruction and may include abdominal pain, nausea and weight loss –11. TherUS scan reveals highly echogenic areas but is often not diagnostic. CT abdomen is the investigation of choice for conclusive diagnosis and well-defined heterogeneous masses, separate from the gastric lumen wall, are seen. If there is obstruction, dilated loops may also be present , 6.Surgical intervention has been previously reported as the only way for removing a bezoar, nowadays it is indicated only after failure of other conservative treatments such as endoscopy and pharmacological approaches or the recurrence of treatment-related complications .Pharmacological strategies include the fragmentation by using the Cola-treatment with Cola direct injection into the bezoars to solve it or carbonated liquid and enzymatic dissolution with papaine which hydrolyzes the proteins .G. Grande et al. [Endoscopic approaches utilize different devices to obtain the fragmentation of the bezoars such as snares, forceps, baskets, electro-hydraulic lithotripters, needle-knife and argon plasma coagulation; a recent technique reported by e et al.  demonstre et al. . Large bSince many of these patients suffer from psychiatric pathologies with emotional problems, mental retardation and eating disorders, psychiatric counselling plays an important role in order to prevent bezoar recurrence. Although studies on the pharmacotherapy of trichotillomania remain inconsistent, some patients seem to respond to fluoxetine or other serotonin reuptake inhibitors . ParentaIn summary, the Rapunzel syndrome is an under-diagnosed entity that has to be considered in children and adolescents, expecially female, referring to pediatric emergency department with IDA and abdominal pain, expecially if an history of PICA is reported. Early diagnosis and an appropriate therapy can reduce morbidity and mortality. Gradual re-feeding after surgery allows adequate catch-up weight with normalization of haematochemical nutritional parameters. Psychological counselling plays a pivotal role in order to prevent PICA and related therefore bezoar recurrence.


A 49-year-old male who attended our hospital due to a history of left hearing loss over a period of 2 years, associated to otalgia, and vertigo to which bleeding in the left ear and facial paralysis had been added in the last 4 months. He reported the simultaneous onset of a left-sided neck swelling with slow growing. After this, he developed loss of sensation of taste on the posterior third of the tongue and swallowing dysfunction, dysphonia, atrophy of the trapezius and sternocleidomastoid muscle and deviation and atrophy of tongue toward the affected side. On physical examination, the mass was found to be painless, soft, pulsating and semifixed. During the otoscopic examination, a pulsatile erythematous lesion of vascular appearance was noted in the external auditory canal. The audiometric test revealed severe left mixed hearing loss. A Doppler ultrasound was performed, which revealed a hypervascularized tumor in the left-sided neck that extended to the skull base. An axial and coronal computerized tomography (CT) scan was taken, revealing a soft tissue lesion extending from the border of II and III neck region to the middle ear and external auditory canal, causing large jugular bulb, hypoglossal canal and temporal bone erosion. This mass avidly enhanced after CT angiography. Following the results of preoperative examinations, diagnosis of simultaneous left glomus vagale, jugulare and tympanicum was confirmed. As the tumor was unresectable, the patient received fractionated radiotherapy associated with iterative stereotactic radio surgery. The patient has been stable over the last two years.


An 11-year-old boy underwent ligation of sac for left congenital hydrocele. In the immediate postoperative period, he developed bleeding per rectum and obstructive features. Intramural hematoma of sigmoid colon was detected in diagnostic laparoscopy and confirmed by laparotomy. Sigmoidectomy with colorectal anastomosis was done. Postoperative period was uneventful.How to cite this article: Jagannathan M, Krishnamurthy G. Postoperative Sigmoid Apoplexy: A Rare Entity in Pediatric Gastroenterology. Euroasian J Hepato-Gastroenterol 2014;4(2):110-112. Intramural hematoma of the alimentary tract is a rare entity posing diagnostic challenge. It can occur from the esophagus to the rectum.An 11-year-old boy was diagnosed with left-sided congenital hydrocele and underwent left processus vaginalis sac ligation under caudal block. His preoperative blood investigation including complete hemogram, bleeding time and clotting time were within normal limits. Patient complained of passing blood admixed with stools in the first postoperative day. On examination, abdomen was soft and per rectal examination revealed bloodstained finger stall. Complete hemogram, platelet count and coagulation profile remained normal. Abdominal X-ray showed dilated small and large intestine with a distal abrupt cut off at the level of sigmoid colon . Differe3 They can be either single or multiple. In majority, the hematoma is found in the submucosal layer splaying the adjacent layers. In contrast to bowel gangrene, in intramural hematoma the viability of the mucosa is preserved. Blunt trauma abdomen is the most common etiological factor. Non-traumatic intramural hematoma associated with anticoagulant usage, coagulation disorders and vasculitis.4 Iatrogenic injury causing intramural hematoma of the ascending colon following cholecys-tectomy has been reported.5 Primary or ‘idiopathic’ intramural hematoma that occurs without predisposing conditions constitute less than 1% of this disease.2McLauchlan was the first person to describe the entity of spontaneous intramural hematoma in 1838.Because of its rarity and benign presentation, the clinical suspicion is seldom made and the diagnosis usually established after radiological imaging or surgical exploration. Varied presentations of this entity include acute conditions like intestinal obstruction, dissection up to serosa resulting in hemoperitoneum and perforation of the weakened bowel wall.6The sonographic appearance of acute intramural hematoma consists of a thickened and echogenic sub-mucosal layer. Contrast-enhanced CT shows intramural hyperdensity of the circumferentially narrowed lumen. Magnetic resonance imaging (MRI) findings include a T2-weighted high-signal intensity ring in the bowel wall surrounding the luminal narrowing.1 One study has hypothesized that during straining, the abdominal pressure increases and the rectum also contracts. The contracted rectum increases the intramural pressure, which leads to decreased vascular compliance and rupture, thus causing intramural hematoma of the sigmoid colon and rectum.1Idiopathic intramural hematomas of the colon and rectum have rarely been reported.7 The concept of draining the hematoma is not followed as it might increase the risk of bleeding, serious infection and weaken the bowel wall predisposing to perforation.8 In our case, in view of the limited non-expanding bowel segment involved and to avoid a second surgery to reverse colostomy, we proceeded with resection of affected bowel and colorectal anastomosis.Most patients with intramural hematomas present with intestinal obstruction. Conservative therapy is the initial line of management in intramural hematoma because the hematomas will undergo spontaneous resorption and any underlying coagulation disorders engraves the patient for a definitive procedure. The tamponade effect of the hematoma over the bleeder during conservative therapy could curtail bleeding. However, treatment decisions are also influenced by the symptoms and clinical findings. Surgical intervention is required in scenarios where the cause of obstruction is not known or in patients with complete obstruction or who have failed medical management.The parents were counseled regarding the unrelated postoperative complication and the need for surgical intervention in the setting of acute intestinal obstruction. They have been on regular follow-up as advised.9 reported a case of 16-year-old boy with intramural hematoma of sigmoid colon after left inguinal hernioplasty. The author attributed the hematoma to a possible needle prick injury during local anesthesia. In our case, patient underwent sac ligation under intravenous sedation and caudal block. Preoperative and postoperative blood workup indicated no evidence of coagulation defects. The patient did not have clinical features of systemic vasculitis. With histopathological examination showing no evidence of vascular anomalies or vasculitis and angiogram revealing normal study, the possibility of idiopathic intramural hematoma has to be entertained.The etiology of the intramural hematoma could not be clearly identified. Patient did not undergo preoperative bowel preparation in the form of enema. In 1914, VogelIdiopathic intramural hematoma is a rare disorder affecting the gastrointestinal system. Knowledge regarding the predisposing factors and their presence in acute abdomen should arouse clinical suspicion. Imaging modalities play a pivotal role in confirming the diagnosis. Though continuous monitoring is the recommended line of management, surgery is indicated in case of failed conservative approach as in our case.


Primary obstructive megaureter is relatively uncommon in adults. This condition usually regresses spontaneously or is treated during infancy. It can remain asymptomatic for decades until adulthood when symptoms may manifest in the event of complications or during a routine radiologic imaging. Primary obstructive megaureter has been reported to favor stone formation in the upper urinary tract.We present the case of a 35-year-old Moroccan man who had a 10-year history of intermittent left flank pain and hematuria. A computed tomography urogram revealed a left megaureter with giant ureteral and renal calculi.Primary obstructive megaureter should be a differential diagnosis in an adult with hydroureteronephrosis associated with urolithiasis especially when there is kidney impairment. Through this case report we will discuss the diagnosis and management of primary obstructive megaureter associated with urolithiasis in adults. Although primary obstructive megaureter (POM) is common in children, it is relatively uncommon in adults . This caA 35-year-old Moroccan man presented with intermittent left flank pain and macroscopic hematuria of 10-year duration. He had no relevant medical history apart from passing out stones on two occasions. He had taken only ibuprofen occasionally to relieve his pain.2. No other clinical signs were found after a complete physical examination.A physical examination revealed that he was in a very good general condition. He was afebrile. His blood pressure was 120/80 mmHg. He had a slight left flank pain with no palpable mass. His body mass index (BMI) was 27 kg/mA blood test revealed the following data: hemoglobin (Hb) 13.4 g/dl, white blood cells (WBC) 7500/mcL, C-reactive protein (CRP) 20 mg/L, blood urea nitrogen (BUN) 0.36 g/L, creatinine 11 mg/L, sodium 140 mEq/L, and potassium 3.8 mEq/L.Proteus mirabilis. A kidney, ureter, and bladder (KUB) X-ray showed two giant ureteral stones and a left renal stone  10,000/ml, and crystals negative. A urine culture tested positive; it grew Abdominal ultrasonography (US) showed severe hydroureteronephrosis. An intravenous pyelogram (IVP) showed no concentration and excretion at 1 hour from his left kidney consistent with a nonfunctioning left kidney Fig. .Fig. 2InComputed tomography urography objectified an advanced hydroureteronephrosis associated with two giant stones in the abdominal and pelvic ureter respectively and another stone in the left inferior renal calyx Figs.  and 4. TWe established the diagnosis of nonfunctioning left kidney secondary to urolithiasis. Surgery was indicated. Our patient had a left nephroureterectomy. The distal segment of the ureter close to the ureterovesical junction appeared narrow suggestive of POM. Histopathologic examinations of the specimen confirmed our suspicion.Gross examination of the specimen (left nephroureterectomy): the left kidney measured 13×7×4 cm; the left ureter appeared dilated and measured 18×2.5 cm containing multiple stones. A cut section of the left kidney showed multiple cystic lesions in the renal parenchyma. Microscopic examination of the specimen: the renal parenchyma showed fibrosis of the glomerular, a pseudo-thyroid appearance of the tubules, and interstitial lymphoplasmacytic infiltrate. There were metaplastic changes in the urothelium of the ureter with no dysplasia. No lesions of malignancy were found.His postoperative course was unremarkable. He had no complaints after 6 months of follow-up. His renal function is stable .Our case presents a megaureter associated with ipsilateral renal and ureteral calculi. The underlying cause which is POM could only be established during preoperative observation aided by histologic examination of the surgical specimen. It is less helpful to use imaging to establish the diagnosis of POM when there is kidney impairment as it is impossible to explore the diseased ureter via IVP.There is no definition for megaureter in adults. However, the British Association of Pediatric Urologists (BAPU) defined a ureteric diameter over 7 mm as abnormal . POM is POM is relatively common in children with an increasing incidence since the advent of fetal US. In adults, this condition is quite uncommon and only occurs after decades of remaining asymptomatic without any spontaneous regression. Symptoms occur eventually in the event of complications such as recurrent urinary infection, recurrent flank pain, urolithiasis, and kidney function impairment , 4.Diagnosis of POM is greatly dependent on radiological imaging. The criteria for diagnosis of POM includes dilated ureter, lower end of ureter ending in a smooth taper, absence of vesicoureteral reflux (VUR), absence of bladder outlet obstruction, and absence of secondary causes of lower ureteral obstruction –6.The presence of calculi in the upper urinary tract associated with a nonfunctional kidney makes it challenging to easily establish the diagnosis of POM in an adult. It can be mistaken for hydroureteronephrosis secondary to ureteral stone obstruction. The reason being that POM associated with urolithiasis is uncommon in adults. In addition, it has clinical and radiological features similar to obstructive urolithiasis especially when there is a nonfunctional kidney.Urolithiasis secondary to POM can be located in any dilated segment of the ureter as well as in the dilated renal calyces. The stones can either be in the ureter or in the renal pelvis and calyces as reports have shown in the literature , 7, 8. IPOM is predominant in males and is often unilateral affecting the left ureter , 10.IVP and CT urography are the most promising imaging modalities that can ascertain the diagnosis of POM when urolithiasis is involved. They show an entire or partly distended ureter with narrowing of its lower distal end at the ureterovesical junction. They show the presence of stones in the distended ureter. Stones may be present in the distended renal pelvis and calyces as well. When the affected kidney is nonfunctional, IVP and CT urography cannot reveal the obstructed ureter that will help establish the diagnosis for POM as in our case. Therefore, the diagnosis may go unnoticed or be suspected during surgery when a narrowed lower end of the ureter is observed as in our case. Histopathologic examination of the surgical specimen can reaffirm POM as the underlying cause as observed in our case.A suspicion of POM after IVP or CT urography indicates that the following minimum investigations be conducted: (1) voiding cystourethrogram to rule out VUR and bladder outlet obstruction , 12; andRetrograde or antegrade ureteropyelograms are helpful tools to confirm the diagnosis of POM in cases where the kidney is nonfunctional.Histologic findings on the nonfunctional distal end of the ureter can reveal abnormalities suggestive of POM .Urolithiasis associated with POM in the adult requires surgery . The goaPOM complicated by urolithiasis in an adult can be easily mistaken for ureterohydronephrosis secondary to urolithiasis as these conditions have similar clinical manifestations and radiological imaging cannot easily differentiate between them, especially when there is renal function impairment. Radiological imaging appears to be a very useful tool to differentiate between these conditions and to avoid any errors in diagnosis.IVP and CT urography are very important diagnostic tools to identify a POM. Voiding cystogram and cystoscopy are required to rule out bladder outlet obstruction and any secondary causes of obstructed ureter in order to confirm the diagnosis of POM.Urolithiasis associated with POM in adults requires surgery in order to avoid renal function impairment and other complications.


Calcium apatite deposition disease (CADD) is a common entity characterized by deposition of calcium apatite crystals within and around connective tissues, usually in a periarticular location. CADD most frequently involves the rotator cuff. However, it can theoretically occur in almost any location in the musculoskeletal system, and many different locations of CADD have been described. When CADD presents in an unexpected location it can pose a diagnostic challenge, particularly when associated with pain or swelling, and can be confused with other pathologic processes, such as infection or malignancy. However, CADD has typical imaging characteristics that usually allows for a correct diagnosis to be made without additional imaging or laboratory workup, even when presenting in unusual locations. This is a review of the common and uncommon presentations of CADD in the appendicular and axial skeleton as well as an updated review of pathophysiology of CADD and current treatments. Calcium apatite deposition disease has been given many names  but is most commonly known as calcific tendinitis. It is a relatively common phenomenon characterized by formation of calcium deposits both in and around tendons and other connective tissue structures. Calcific tendinitis most commonly occurs in between the ages of 30–60, although cases have been described in patients as young as 3 years old , 2. A laHistorically, calcium deposits in calcific tendinitis have been thought to represent collections of hydroxyapatite crystals leading to the used of the term hydroxyapatite deposition disease (HADD) to describe this disease process , 8. HoweCalcific tendinitis typically presents with a single site of involvement. However, bilateral presentation of shoulder calcific tendinosis is not uncommon, occurring in anywhere from 5 to 23% of patients in larger studies of rotator cuff calcific tendinitis –18. BilaCalcium apatite deposition is often seen incidentally on radiographs in asymptomatic patients. When patients are symptomatic, symptoms can vary from an acute episode of severe pain to chronic mild discomfort. Typically, acute episodes of pain are single occurrences that resolve spontaneously, although patients can experience recurrence of pain months after the initial episode . OccasioThe diagnosis of calcific tendinitis is most frequently made on radiographs. Calcifications have been described typically appearing as fluffy, ill-defined, and inhomogeneous or as discrete, homogeneous, and well defined  8, 15, , 15, 28.After radiographs, magnetic resonance imaging (MRI) is the most common modality used to diagnosis calcific tendinitis, as it confirms the presence of inflammation associated with the acute symptomatic phase of calcific tendinitis and excludes other etiologies of pain when the presenting symptoms are atypical. MRI appearance of the calcifications varies depending on the radiographic appearance of the calcifications, and the degree of soft tissue inflammation depends on the stage of the calcifications. In the acutely symptomatic phase, soft tissue edema will typically be seen surrounding the region of calcification  4, 15, , 15, 29.Ultrasound is not commonly needed to make the diagnosis of calcific tendinitis, but it is commonly used in image-guided treatment of the calcifications. Four morphologies of tendon calcification have been described on ultrasound : arc-shaNuclear medicine exams are rarely used to diagnose calcific tendinitis. Not surprisingly, cases of calcific tendinitis have been described as demonstrating increased radiotracer activity on both positron emission tomography and technetium-99m bone scans  32–34].–34.32–34Rarely, calcific tendinitis can extend to involve the underlying bone at the tendon attachment site. Approximately 80% of osseous involvement by calcific tendinitis occurs at the proximal femur and proximal humerus with the femur diaphysis most commonly involved followed by the humerus tuberosities. Cortical erosion  is the mSpine calcific tendinitis has almost been exclusively described to involve the upper oblique fibers of the longus colli tendon at the C1-C2 level . A few cCalcific tendinitis of the spine is much less common than involvement of the shoulder. A study by Horowitz et al. estimated the annual incidence of symptomatic longus colli calcific tendinitis at 0.5 cases per 100,000 people . Neck paPrevertebral edema is almost always present in symptomatic patients , 39. CalThe shoulder is the most common location of calcific tendinopathy by a wide margin, with the rotator cuff being the most common area of involvement . The supThe association between rotator cuff calcific tendinopathy and rotator cuff tear is controversial. Jim et al. described seeing rotator cuff tears on arthrography in 28% of patients with calcific tendinopathy, and a study of 74 rotator cuff tears by Wolfgang found tendon calcification in 23% of patients with rotator cuff tears , 48. HowAlthough rare, calcific tendinitis is also known to involve the long head of the biceps tendon and pectoris major insertion . CalcifiPectoralis major calcific tendinitis typically presents focal tenderness over the anterior aspect of the proximal third of the humerus at the attachment site of the pectoris major tendon , 55. TheThe elbow is the least common joint described to be involved in calcium apatite deposition, although this is likely due to underreporting as calcific tendinopathy of the distal biceps and common extensor/flexor tendons is not an uncommon finding on radiographs of the elbow. Most commonly, calcific tendinitis has been described involving the distal biceps tendon , 58, 59.Hand and wrist involvement by calcium apatite deposition disease has been well described in the literature. Calcium apatite can present as calcific periarthritis involving the interphalangeal or metacarpal phalangeal joints  or as caAfter the shoulder, the hip is the most commonly involved region for calcific tendinitis . The gluRectus femoris calcific tendinitis typically presents as focal tenderness over the anterior-inferior iliac spine and limited flexion of the hip . SymptomGluteus medius calcific tendinitis occurs at the gluteal tendon attachments to the greater trochanter , 75. CalOther regions of calcific tendinitis around the hip have been described, including distal psoas tendon, joint capsule , ligamenCalcific tendinitis of the knee is rare with only a few case reports of knee involvement in the literature. Calcific tendinitis/periarthritis has been described to involve the lateral collateral, medial collateral , and antCADD involvement of the foot and ankle has only been sparsely reported in the literature. The most commonly described area of involvement is the great toe, either presenting medial to the first metatarsophalangeal joint or at the flexor hallucis brevis tendon just proximal to the hallucal sesamoids  4, 90]., 90.4, 9CADD can be confused with several entities, particularly if a clinician is not aware of the many different locations CADD can present. Acute symptomatic CADD is most commonly mistaken for a traumatic or infectious process, particularly when it occurs in the longus colli of the cervical spine . The preChronic symptomatic CADD is more commonly confused with either late sequela of trauma  or with malignancy. Heterotopic ossification can be differentiated from CADD by the presence of a corticated margin around the heterotopic ossification, which is not present in CADD. The bony erosion and periosteal reaction seen in long-standing CADD can make differentiating CADD from a soft tissue malignancy challenging. In this setting, the absence of a discreet soft tissue mass in conjunction with calcification occurring at a typical location of CADD can help distinguish CADD from a neoplastic process.There is no consensus for appropriate treatment of CADD. Pain in most cases of acute symptomatic calcific tendinopathy will resolve with conservative management, and most calcification will decrease in size or resolve . Cases rThere is little quality research comparing effectiveness of different minimally invasive therapies for CADD. A meta-analysis of barbotage studies by Vignesh et al. in 2015 concluded that while there are many low quality studies showing barbotage to be effective in reducing pain and size of calcium deposits, there is only weak evidence that barbotage is more effective than no therapy or needling alone . An addiCADD is a common entity that can present in many different locations. Clinically, CADD can be divided into an acutely symptomatic phase and chronic or asymptomatic phase. Both of the phases have typically imaging characteristics allowing the diagnosis of CADD to confidently be made even when presenting in an atypical location. Acutely symptomatic CADD will usually improve with conservative therapy alone, while chronic CADD may be treated with multiple minimally invasive techniques or surgery. There is conflicting evidence on the best treatment for persistent symptomatic CADD. Both ESWT and barbotage are commonly employed treatment methods that have shown potential for providing symptomatic relief. However, there are few quality studies comparing different treatment methods, and further research is needed to determine optimal management of CADD.