Hemangioblastomas are benign neoplasms, which are highly vascularized and have a slow-growing rate that typically affect the central nervous system; they account for about 1-2.5% of all intracranial tumors and for approximately 2-3% of all intramedullary neoplasms. We present a clinical case of cerebellar hemangioblastoma with six years of evolution, which illustrates the diagnostic difficulties that often arise, especially when the clinical and imaging characteristics escape those usually described and when other clinical findings appear as confounding factors. A 17-year-old female was initially admitted to the emergency department (ED) with a holocranial headache, gait imbalance, and vomiting. A brain magnetic resonance imaging (MRI) was done and a rounded lesion was detected in the left cerebellar hemisphere, hypointense in T1 and hyperintense in T2, with annular contrast enhancement. Several hypotheses for diagnosis were made, and the patient was subjected to several therapies, with periods of remission of symptoms interleaved with periods of worsening. After imaging suggestive of hemangioblastoma on routine brain MRI, the tumor was excised surgically and the histopathology confirmed the diagnosis. In the control brain MRI exams performed six and 24 months after surgery, no evidence of tumor recurrence was detected, and the patient remained asymptomatic. In conclusion, although these are rare neoplasms, it is essential to always consider hemangioblastomas in the differential diagnosis of cases with compatible clinical and radiological findings. A wrong or late diagnosis may lead to the use of unnecessary and harmful therapies as well as the appearance of potentially preventable complications if these tumors are handled correctly and timely. The term “hemangioblastoma,” originally introduced by Cushing and Bailey in 1928, describes a slow-growing, highly vascularized benign neoplasm that typically affects the central nervous system (CNS) . They caIn nearly 70-80% of the cases, hemangioblastomas appear as isolated, sporadic lesions. The remaining cases are associated with von Hippel-Lindau disease (VHLD), an inherited disease of autosomal dominant transmission characterized by a predisposition to the occurrence of multiple hemangioblastomas and other visceral lesions that develop throughout life . EssentiDespite their benign growth behavior, these tumors can become important causes of morbidity and mortality, with specific symptoms depending essentially on anatomical location and growth pattern ,9.Standard treatment consists of surgical excision of symptomatic tumors when the benefits of the procedure outweigh the surgical risk ,10-13.Although considered rare neoplasms, it is important to always consider hemangioblastomas in the differential diagnosis of cases that present with clinically compatible radiology. Misdiagnosis or late diagnosis can lead to the use of unnecessary therapies and, eventually, harm to the patient, as well as to the emergence of potentially avoidable complications if handled correctly and in a timely manner. The clinical case presented here, referring to a cerebellar hemangioblastoma, illustrates well the diagnostic difficulties that often arise associated with this type of neoplasm.A 17-year-old female, with no medical problems, presented in the emergency department (ED) with holocranial headache, unbalanced gait, rotational vertigo, and vomiting with four days of evolution. On examination, diplopia to left lateralization of the gaze was highlighted, nystagmus in the extreme positions of the gaze, gait deviation to the left, a slight fall of the left upper limb in the outstretched arms test, and balance was maintained in the Romberg test, without visual interference. Brain magnetic resonance imaging (MRI) was performed with the administration of gadolinium contrast, which showed a lesion in the left cerebellar hemisphere, hypointense on T1 and hyperintense on T2, with annular contrast uptake. A diagnostic hypothesis of multiple sclerosis was suggested, and therapy with methylprednisolone was performed for five days. Control MRI was performed on the last day of therapy with dimension reduction of the cerebellar lesion.There was an improvement in the clinical picture as well as a normalization of the neurological exam, with only left gait deviation persisting. In view of the diagnosis, the patient developed a reactive anxiety-depressive condition and began follow-up in a psychiatric consultation. Six months later, she went to the ED because of symptoms similar to the initial ones, with evidence, on neurological examination, of diplopia in the combined gaze to the left and deviation to the left during gait. A new MRI was performed, showing a lesion in the left cerebellar hemisphere with characteristics similar to the initial one. Remedicated with methylprednisolone for three days, but with no improvement during hospitalization. Somatosensory, visual and auditory evoked potentials without alterations, and lumbar puncture without oligoclonal bands and with negative serology. Despite the images obtained on MRI, the hypothesis of demyelinating disease was discarded, and the possibility of sequelae of cerebellar ischemic stroke was assumed. In view of this hypothesis, an etiological study of stroke in young people was carried out, which showed positive homozygosity for the 4G allelic variant of the plasminogen activator inhibitor-1 gene (PAI-1) and exuberant aneurysm of the interauricular septum with permeable foramen ovale with the passage of stirred serum in copious amounts. The patient underwent surgical closure of the interatrial communication with autologous pericardium approximately 16 months after the initial clinical condition. Medicated for ambulatory care with antiplatelet and oral contraceptive suspension. There were no intercurrences for two years after surgery, except for an episode of thrombosis of the left common femoral vein, which was started with oral hypocoagulation with warfarin, which was maintained for six months.After this period, she develops intense holocranial headache and nausea. On neurological examination, oscillations to maintain the orthostatic posture without enlargement of the base, gait with lateral deviations to the left, and fine tremors in the left upper limb on the finger-nose test. A brain MRI was done, which again showed the presence of abnormal blood vessels in the vicinity of the nodular lesion . After discussing the case with neuroradiology, the imaging characteristics of the lesion made it possible to establish a differential diagnosis between tuberculoma, primary or secondary tumoral lesion and arteriovenous malformation. It should be noted that the interference of a generalized anxious component in the clinical picture was also considered. A full analytical and microbiological studies of the blood, urine, and cerebrospinal fluid were done and we found a 20 mm positive Mantoux test. Despite the positive Mantoux test, the stability of the lesion dimensions over approximately four years, as well as the presence of abnormal circulation in the periphery, were not suggestive of tuberculosis. It is also important to mention the absence of contacts with people with active infection and an unaltered chest x-ray. However, after discussing the case with infectiology, medication with rifampicin, isoniazid, and pyridoxine was started, but suspended after six months due to stability of the lesion documented in a new control brain MRI. Due to diagnostic uncertainty, the patient was evaluated in a neurosurgery consultation six years after the onset of the clinical picture. Control MRI was performed and the radiological aspects, after comparison with previous exams, were suggestive of hemangioblastoma Figure .The patient underwent elective tumor excision surgery through a left paramedian suboccipital craniotomy with total macroscopic tumor removal. The neuropathological report confirmed that the excised tissue was a benign angiomatous neoplastic lesion, corresponding to a cerebellar hemangioblastoma. It should be noted that there is no family history of similar lesions in any region of the CNS, but a detailed imaging study was carried out, including MRI of the cervical and dorsal spine, abdominal and pelvic CT, as well as retinal angiography, to exclude VHLD; none of the exams revealed lesions with pathological significance. The patient refused to carry out a genetic study to investigate the mutation in the von-Hippel Lindau (gVHL) gene. Control encephalic MRIs were also performed at six and 24 months after surgery, which showed no evidence of tumor recurrence or new cranial lesions.Although considered rare neoplasms, accounting for only 1-2.5% of all intracranial neoplasms, hemangioblastomas comprise about 7-12% of posterior cranial fossa tumors, constituting the most common type of primary intra-axial tumor of those that form in this location in adults . Thus, iIt is known that approximately 95% of infratentorial hemangioblastomas are located in the cerebellum, with the cerebellar hemispheres being more commonly affected than the vermis . PosteriIn this case, the diagnosis was probably delayed due to several factors: the patient had symptoms compatible with the location of the lesion in the left cerebellar hemisphere, but some symptoms emerged that could not be explained by the lesion, but rather by an occasional anxious-depressive condition; the initial radiological features, seen on encephalic MRI, were not suggestive of hemangioblastoma; in addition, throughout the etiological investigation process, new clinical findings compatible with other diagnostic hypotheses emerged. It should be noted that the symptomatology of hemangioblastoma is not specific and depends on the anatomical location of the tumor, its growth pattern, the compressive effect it causes on adjacent structures, as well as the surrounding edema, which can make the diagnosis even more difficult .Although the clinical outcome was favorable after the tumor excision surgery, fatal complications could have occurred, namely, massive hemorrhage in the posterior cranial fossa. Although the rich vascularization and asymptomatic and microscopic intratumoral hemorrhages are characteristic features of this type of tumor, massive hemorrhage is a very uncommon event (0.0024 per patient per year). It may, however, be the initial manifestation .After the definitive pathological diagnosis of cerebellar hemangioblastoma, the patient underwent an extensive clinical study in order to exclude the possibility of VHLD. However, a genetic study was not carried out to detect the germline mutation associated with gVHL, responsible for the disease. This was due to the patient's refusal to perform the study. Apparently, the patient's hemangioblastoma is sporadic as there is no family history of similar lesions and no additional lesions were detected in the studies performed, but the diagnosis of VHLD cannot be definitively ruled out. On the one hand, the patient was 17 years old when the symptoms began, a very early age for it to be a sporadic lesion, whose age at diagnosis is usually between 30 and 65 years old ; on the Special attention should be paid to the underdiagnosis of VHLD in patients with apparently isolated lesions and no evidence of family history, with some authors recommending genetic screening in all patients diagnosed with CNS hemangioblastoma, even if apparently sporadic . It woulPatients have a very favorable long-term prognosis after complete surgical resection of the tumor. However, these neoplasms have recurrence rates of up to 27% with a symptom-free interval of, on average, five years ,13. No eThe clinical case presented, referring to a cerebellar hemangioblastoma, illustrates well the diagnostic difficulties that often arise when the clinical and imaging characteristics are beyond those usually described and when other individual characteristics and clinical findings that can act as confounding factors are present. This case involved approximately six years of simultaneous follow-up by several medical specialties and in different hospitals, from the onset of symptoms to the appropriate diagnosis and treatment of the cerebellar hemangioblastoma. During this period of time, several diagnostic hypotheses were raised for the lesion found in the cerebellum without, however, ever having considered the hypothesis of hemangioblastoma, and the patient, still very young, was subjected to the use of unnecessary and, eventually, stigmatizing therapies. Misdiagnosis or late diagnosis can lead to the use of unnecessary therapies and, eventually, harm to the patient, as well as to the emergence of potentially avoidable complications if handled correctly and in a timely manner. Thus, although these are rare neoplasms, it is essential to always consider hemangioblastomas in the differential diagnosis of cases that present compatible clinical and radiological findings.


Intestinal knot formation, in which two segments of the intestine become knotted together, can result in intestinal obstruction. An ileo-ileal knot refers to knot formation between two ileal segments and is a very rare benign disease. We report a case of strangulated bowel obstruction caused by true ileo-ileal knot formation.An 89-year-old woman was referred to our hospital with the diagnosis of intestinal obstruction. Contrast-enhanced computed tomography revealed the small bowel forming a closed loop, with poor contrast effect. Based on the findings, the patient was diagnosed as having strangulated bowel obstruction, and emergency surgery was performed. At laparotomy, two segments of the ileum were found to be tied together forming a knot, and both segments were necrotic. Although it was necessary to release the strangulated small bowel, we did not immediately release the knot, but first proceeded with ligation of the mesenteric vessels to the strangulated small bowel to prevent dissemination of toxic substances from the necrotic bowel into the systemic circulation. The surgery was completed with resection of the necrotic ileum and anastomosis of the small intestine. The postoperative course was uneventful, and the patient was discharged home.We encountered a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. Resection of the necrotic small intestine without releasing the knot could be performed safely, and might be considered as an option of surgical procedure. Intestinal knot formation is the condition, where two intestinal segments become tied together to form a knot, resulting in intestinal obstruction with impaired blood flow. Almost all intestinal knot formation are found between the sigmoid colon and ileum, whereas knot formation between two segments of the ileum, the so-called “ileo-ileal knot,” is rare . There hThe patient was an 89-year-old woman who visited a neighborhood hospital 4 h after developing abdominal pain and vomiting of sudden onset. She was referred to our hospital 2 h later with the diagnosis of intestinal obstruction. She had a history of undergoing cesarean sections. On arrival at our hospital, her vital signs were stable; examination revealed that she was 145 cm tall and weighed 36.9 kg . She had severe tenderness in the lower abdomen, but no signs of peritoneal irritation. Blood tests showed an elevated white blood cell count, although the serum C-reactive protein (CRP) was normal. Blood gas analysis showed mild acidosis, with a pH of 7.383, and a base excess (BE) of − 3.7. Contrast-enhanced computed tomography (CT) revealed a small bowel forming a closed loop, with poor contrast effect, and dilatation of the oral side of the small bowel (Fig. At laparotomy, bloody ascites was observed. Two segments of the ileum were tied together forming a knot, and both segments were necrotic due to impaired blood flow Fig. . There wThe resected specimen showed the two intestinal segments wrapped together forming a knot, as indicated by the intraoperative diagnosis, and the strangulation was released by untying the knot Fig. . There wThe postoperative course was uneventful, and the patient was discharged on the 13th postoperative day.Taylor et al. classified bowel knots into two types: true knots, in which one intestinal segment passes through a loop formed by another intestinal segment, and pseudo knots, in which the intestinal segments are wrapped around each other without actual formation of a knot . The conIntestinal obstruction caused by ileo-ileal knot formation is rare, and only 12 cases have been reported since 1990, including in the Japanese literature –10 (TablAlthough the intestinal tract entering another intestinal loop should be free of adhesions, about a half of the previously reported cases had a previous history of laparotomy. Kondo et al. suggested that adhesions may play a role in knot formation . In our Preoperative diagnosis of knot formation is extremely difficult, and in most previously reported cases, the condition was only diagnosed as strangulated bowel obstruction prior to the operation. CT is often not performed in patients of advanced age or cases in developing countries. In our case, preoperative CT revealed the small bowel in a closed-loop formation, and the diagnosis of strangulated bowel obstruction was made; a retrospective review, however, confirmed two, not one, closed-loop formations. As Matsuoka et al. have pointed out previously , the “doTrue ileo-ileal knot formation cannot be prevented; therefore, immediate operation is required. In terms of the most appropriate surgical procedure, there is no consensus as yet as to whether the ileo-ileal knot should be released or not before resecting the bowel. Some suggest that the knot should be released first to determine the extent of salvageable small bowel, so as to avoid excessive bowel resection . In factThere were no deaths among the cases included in this review. It is considered that appropriate surgery at the right time is associated with a good prognosis.Because of small number of reported cases, we have very limited knowledge of true ileo-ileal knot. Furthermore, almost cases were reported from Japanese institute. True pathogenesis and appropriate surgical procedure for this disease should be assessed in the near future. Considering the background of lack of understanding of the disease, our case report may be helpful to understand the therapeutic strategy of true ileo-ileal knot.We encountered a case of strangulated small bowel obstruction caused by true ileo-ileal knot formation. Even though we were able to operate on the patient relatively early after the symptom onset, the involved bowel segment was found to be necrotic due to the severe blood flow restriction. Resection of the necrotic small intestine without releasing the knot might be considered as an option of surgical procedure.


We report the case of a patient with a giant Brunner's gland hamartoma that was pathologically diagnosed by endoscopic mucosal resection. A 69‐year‐old woman presented with intermittent abdominal pain, and imaging revealed a smooth saccular submucosal tumor, 40 mm in diameter, on the anterior wall of the duodenal bulb. Brunner's gland and smooth muscle tissue were observed on endoscopic ultrasound‐guided fine‐needle aspiration biopsy, which resulted in the preoperative diagnosis of a duplication cyst. However, subsequent endoscopic mucosal resection established a final histopathological diagnosis of Brunner's gland hamartoma. Brunner's gland hamartoma (BGH) is a rare condition that accounts for approximately 0.01% of benign duodenal diseases.A 69‐year‐old woman presented with a history of occasional epigastric pain since her early childhood, but she had no symptoms, such as vomiting or anemia. Moreover, there was no particular history of illness. The patient was referred to the hospital because the screening endoscopy revealed a duodenal submucosal tumor. No abnormalities were observed in the physical examination and blood sample results. Upper gastrointestinal endoscopy revealed duodenal abnormalities, including a 25‐mm smooth saccular submucosal tumor on the anterior wall of the bulb. On endoscopy, we encountered a positive cushion sign and made a diagnosis of Brunner's gland hyperplasia. Therefore, the tumor was carefully monitored through annual endoscopy for changes in size and morphology.The tumor diameter increased from 25 to 40 mm in 2 years Figure . FurtherThe patient had epigastric pain since childhood. Her postoperative condition is good.BGH is an extremely rare disease that usually involves the following sites: duodenal bulb, 70%; second (descending) part, 26%; and third (inferior) part of the duodenum, 4%. Tumors sized ≥2 cm in diameter can present with symptoms of upper gastrointestinal bleeding or obstruction.Largely isolated lesions that are symptomatic may be clinically indicative.Smooth muscle bundles are present among the dense proliferation of Brunner's glands in BGH. Similarly, a smooth muscle tissue was observed in the deeper layers of BGH in this case, which was the reason for the preoperative diagnosis of the duplication cyst. We believe that the irregular arrangement of blood vessels in the smooth muscle tissue was the cause of uneven contrast enhancement observed on CT. On histopathology, it was observed that the smooth muscle tissue and Brunner's gland were not uniformly distributed like mirror images; however, the smooth muscle tissue was admixed with a dense growth of Brunner's glands. Therefore, the final diagnosis was BGH rather than a duplication cyst.BGH and duplication cysts are congenital diseases. Duplication cysts have similar presentation, with gastrointestinal symptoms, such as abdominal pain and vomiting,In conclusion, we report a rare case of BGH that could not be diagnosed preoperatively, which could only be diagnosed after EMR via histopathological analysis of the resected tissue.DEN Open.The authors declare no conflict of interest. The author T.I. is an EIC of The authors received no funding from external sources for this manuscript.This study was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.We obtained written consent from the patient prior to publication of the case.


Echinococcus granulosus which can develop anywhere in the human body, but it is most frequently located at the liver. Liver hydatid cyst may rupture into the biliary tract, thorax, peritoneum, viscera, digestive tract, or skin, but its rupture in the gallbladder remains rare. We report a rare case of rupture of liver hydatid cyst in the gallbladder leading to acute cholangitis. The diagnosis was suspected on radiological imaging, and the patient was taken to open surgery which confirmed the imaging findings. The gallbladder and adjacent cyst were excised, and a transcystic drain was placed. Postoperative recovery was uneventful.Hydatid disease is a health problem in endemic areas such as the Mediterranean region caused by  Echinococcus granulosus. The definitive host is usually a dog but may be some other carnivore. Humans are infected incidentally by food and water contaminated by tapeworm eggs. The liver is the most commonly involved organ by Echinococcus granulosus in the form of hydatid cyst which grows slowly.Hydatid disease is a nonimmunizing parasitic zoonosis caused by Liver hydatid cyst can rupture in any part of the biliary system, but the communication with the hepatic bile ducts is most common. Rupture between a hepatic hydatid cyst and the gallbladder is rare .We present a case of rupture of liver hydatid cyst in gallbladder with dilatation of the intrahepatic biliary tree.A 60-year-old female with no significant medical history presented with right upper quadrant pain, icterus with clay-colored stools, and itching for one month. The evolution was marked by fever and chills for 3 days. On admission, the patient's blood pressure was 120/80 mmHg, pulse was 84 beats/min, and temperature was 38.5°C. Physical examination revealed tenderness in the epigastric region and right upper quadrant of the abdomen. There was no hepatomegaly or splenomegaly, and the rest of the clinical examination was without particularities.μL, C-reactive protein (CRP) 15 mg/L, serum glutamic-oxaloacetic transaminase (SGOT) 37 μ/L, serum glutamic pyruvic transaminase (SGPT) 37 μ/L, and total bilirubin 250 mg/L with direct bilirubin 150 mg/L. The patient was diagnosed with cholangitis due to the presence of pain, fever, and jaundice. Radiological examinations were applied to identify the etiology. Abdominal ultrasound revealed a cystic lesion at segment IV of the liver. This formation measures 67/44 mm, and it seems to communicate with the gallbladder which contains multiple stones with compression leading to dilatation of the intrahepatic bile ducts.The laboratory examinations on admission showed white blood cell count (WBC) of 13000/Abdominal CT scan was performed for a better characterization and showed hydatid cyst at segment IV of the liver fistulized in the gallbladder which is multilithiasic with dilatation of the intrahepatic biliary tree .During treatment, the patient was given 10 mg/kg a day of albendazole for hydatid cyst treatment; 1 g (2 × 1) ceftriaxone, and 500 mg (3 × 1) metronidazole were initiated for cholangitis treatment. The patient underwent right subcostal laparotomy which revealed a hydatid cyst of segment IV adherent to the gallbladder with the cholestatic liver. The exploration did not show any other cystic lesions .After using a scolicidal agent in the operating field, resection of the protruding dome along with cholecystectomy was performed . When thThe patient's postoperative course was uneventful, and she was discharged on the 6th postoperative day. Histopathologic examination showed a hydatid cyst with fistula to the gallbladder as we suspected.The patient received albendazole 400 mg twice daily for three cycles. After six months of clinical and ultrasonographic follow-up, no recurrence occurred.Echinococcus granulosus or Echinococcus multilocularis and affects the liver in 70% of cases [Hydatid disease is caused by of cases , 3. It iThe liver (70–80%) and lungs 15–25%) are the most common sites of hydatid cysts, but involvement of other organs is also possible. The exact incidence of extrahepatic cysts is not known . The fra–25% are Clinical presentation consists generally pain localized in the right hypochondrium and rarely in the epigastrium . JaundicUltrasound and computed tomography are very helpful to diagnose hydatid cysts. They may detect hydatid disease in the form of purely cystic lesions or when floating membranes, daughter cysts, or vesicles are recognized . MagnetiThe finding of bile duct dilatation in the vicinity of cystic lesions suggests bile duct compression or presence of a fistula opening into the bile ducts, which are events consistent with hepatic cystadenoma and hydatid cyst, respectively; cystic lesions of segment IV according to Couinaud's classification can lead to compression of the common hepatic duct and the right or left intrahepatic bile ducts . In our Surgical intervention is the optimal treatment in hydatid cyst open in the gallbladder, and treatment options include the sterilization and drainage of hydatid cyst followed by radical  or conservative  excision along with cholecystectomy. Following common biliary duct investigation and biliary lavage, T-tube drainage or transduodenal sphincteroplasty may be carried out, particularly if fistula is larger than 5 mm and if preoperative endoscopic retrograde cholangiopancreatography (ERCP) was not performed . The preAlbendazole or mebendazole should be used in the treatment of hydatid cysts either alone or as a preprocedure or postprocedure prophylaxis . In our Rupture of liver hydatid cyst in the gallbladder is extremely rare even in endemic areas. Treatment remains essentially surgical, and health education of the population in endemic areas remains the best mean of prevention.


Near infrared fluorescence imaging with indocyanine green (ICG) can facilitate the intraoperative tumour localization and therefore a complete resection. Cholangiocarcinoma is an aggressive tumour and complete resection improves the outcome. Therefore, it is necessary to localize the tumour exactly but the translation of the preoperative imaging into the intraoperative setting can be difficult based only on sonography, computed tomography or magnetic resonance imaging.In this case a hepatic lesion suspicious for cholangiocarcinoma was discovered accidentally. Further diagnostics were unable to prove the diagnosis, therefore right hepatectomy was recommended and performed. Preoperatively ICG was administered and near infrared imaging was used intraoperatively clearly localizing the tumour, thus facilitating the resection. The intra- and postoperative course was uneventful.This case report supports the very promising intraoperative use of fluorescence imaging for the localization of superficial hepatic tumours. Timing and correct administration of ICG is important. •Indocyanine green facilitates intraoperative tumour localization and improves outcome.•Cholangiocarcinoma is an aggressive tumour with poor outcome.•Surgery with a negative resection margin improves outcome. The incSince the 1960's indocyanine-green (ICG) has been established in assessing the liver function as it is exclusively metabolized in the hepatic parenchymal cells. ICG emits light at a wave length of around 835 nm when illuminated with near-infrared light and can therefore be used in fluorescence guided imaging with a tissue penetration up to 1 cm . This te1.2ICG staining in hepatic surgery is a trending research topic and guidelines on the use of intraoperative fluorescence are being established. There is an ongoing debate about the exact mode of application of ICG. To support current research we present a case in which intraoperative ICG was used to localize a central intrahepatic cholangiocarcinoma in accordance to the recommendation by Chen et al 1.3Feasibility and effectiveness of intraoperative ICG staining in hepatic surgery has been evaluated since 2008 ,8,12,13.This work has been reported in line with the SCARE criteria .22.1In a 62-year-old Caucasian male patient routine MRI follow-up was conducted yearly due to complex renal cysts. Beside the renal cysts the patient was treated for arterial hypertension with a combination of three antihypertensive drugs. His liver was steatotic, otherwise the patient was healthy.2.2As an incidental finding the MRI detected a subcapsular cystic lesion of 2.8 cm in size between the liver segments V and VIII . The lesMagnetic resonance cholangiopancreaticography (MRCP) showed a slight increase of the subcapsular cystic lesion in size and - in correlation to the sonographic findings - an intrahepatic lesion of 1.7 cm was detected on the border between the liver segments V and VIII with compression of the bile ducts, suspicious for a cholangiocarcinoma . EndoscoDue to the location and the above described negative cytologic findings histological confirmation of the suspected malignant tumour was not possible. The case was discussed at the interdisciplinary tumorboard and right hepatectomy was recommended. Liver function was sufficient for a right hepatectomy as assessed via LiMAx® Test  with a measured value at 492 μg/h/kg .2.3According to most recent recommendations by Chen et al.  10 mg IC2.4The postoperative course was uneventful and the patient discharged nine days after the operation with a normal length of hospital stay according to the local diagnosis related groups system (SwissDRG).Histologic analysis confirmed the diagnosis of a well-/poorly differentiated cholangiocarcinoma (pT2) with two lymph node metastases (pN1). The interdisciplinary board recommended an adjuvant chemotherapy with capecitabine over 6 months in accordance to the BILCAP trial .3With the here presented case we demonstrate that confirming a suspicion of intrahepatic cholangiocarcinoma requires a complex diagnostic workup which maybe time consuming and expensive. In this case, histologic/cytologic samples could not be acquired due to the location of the tumour. The lesion could be localized via MRI but translation into the intraoperative was expected to be difficult. Exact determination of tumour margins is of outmost importance to ensure complete resection with negative resection margins. This improves the outcome after resection of hepatic tumours both primary and metastatic. Intrahepatic cholangiocarcinoma is an aggressive entity with a rising incidence. If not found incidentally first diagnosis usually occurs in advanced disease.This case supports current research that fluorescence guided imaging during hepatic surgery is a safe, easily implementable and cheap method to visualize superficial intrahepatic tumours.Written informed consent was obtained from the patient for publication of this case report and accompanying images during pre-operative consultations. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.No external funding.Exempt from ethical approval.No “First in Man” report.1-Till M. Hempfing2-Thomas Steffen1-T. Hempfing: conceptualization, data curation, writing - original draft preparation2-D. Husarik: resources, data curation, writing – reviewing3-T. Steffen: idea, conceptualization, supervision, writing – reviewing and editingNone to declare.


We reported a patient with Testicular adrenal rest tumors(TARTs) caused by congenital adrenal hyperplasia(CAH). TARTs occur frequently in CAH population with 21-hydroxylase deficiency(21-OHD). There are few reports of TARTs with 3β-hydroxysteroid dehydrogenase deficiency-2 (3β-2HSD).Furthermore,gaint TARTs are rarely mentioned in reported cases involving affected siblings.A 14-year-old male patient was admitted by congenital adrenal hyperplasia with progressively increasing bilateral testicular masses.The Patient and his elder brother had been performed mutational and chromosome analysis and biopsy. Hormonal and anthropometric measurements were performed during endocrine treatments. We successfully performed surgery and excised two 83mm×46mm×44mm and 74mm×49mm×31mm tumors. Our pathology and immunochemistry tests have proven TARTs in patient. At first, both siblings received regular doses of hydrocortisone and fludrocortisones and tumor size regressed. During the one-year irregular intake due to Covid-19 pandemic, endocrine treatment became insensitive and tumor size slowly increased. The gene analysis reported two novel mutations C.776 C>T and C.674 T>A. The C.776 C>T is from father and has been reported. The C.674 T>A inherited from mother and cannot found in gene library and may related to TARTs.This case illustrates inadequate hormone therapy could cause tumor enlargement. It is essential to seek for ultrasound examination once suspected scrotal mass occurred.It is necessary to adjust endocrine medicine or adopt surgery in refractory gaint TARTs. And presence of tunica vaginalis cavity may indicate the severity of TARTs in surgery.The online version contains supplementary material available at 10.1186/s12887-021-02883-x. CAH is defined as autosomal recessive disease group mainly caused by enzymes defects that block adrenocorticosteroid synthesis-metabolism and cause disorders of sex development(DSD),which are common in female births and the reported incidence is about 1: 15,000[2·d) was gradually adjusted to 23 mg/m2·d, which was proven effective by diminshed tumor size. While two siblings often forgot to take medicine on time for one year and did not seek for regular examination due to COVID-19 epidemic in Wuhan. The bilateral TARTs size became slightly larger than pre-treatment and seemed insensitive to HC.A 14-year-old boy was admitted for bilateral scrotal masses for 11 years in our outpatient department. According to the previous documents provided by his family, his parents were normal but his elder brother showed same scrotal masses.When they were 3 years old,the elder brother,who is 10 years older than the younger, accepted serious hypospadias repair surgery in 1999 while the younger in 2009 at Wuhan Children’s Hosptial. In the short postoperative period, this younger child’s skin color became tanned and the color deepen. Although parents noticed that his testicles were slightly larger than peers in progressive pigmented stage, occasionally even with orchialgia, same to childhood of his elder brother, they still ignore it and did not take him to medical treatment until oversize bilateral lumps 5 years later. Thus his parents sent them to Tongji Hosiptal affiliated to Middle China University in Wuhan, and both were diagnosed as TARTs with 3β-2HSD by routine hormone examination to control the disease. The CT image suggested that testis tumor nearly replaced normal testicles tissue and hyperplasia in bilateral adrenal cortex. After Multi-disciplinary discussion, the tumor was proposed to excise to avoid growing up and his parents accepted our advice.After the incision into tunica vaginalis in each side, there is an obvious characteristic that cavity of tunica vaginalis disappeared, we can noticed two hard giant tumorssee Fig.  with sevIn the postoperative week,bilateral scrotum skin folds gradually resumed with subsidence of scrotum swelling and bilateral size obviously decreased comparing with primary manifestation.During the third admission to Shenzhen Children’s Hospital in 2021 July, physical examinations included:Height_146.2 cm(-3 SD), Sitting Height_85.3 cm, Weight_64.5 kg, Pigmented Skin color improved. Tanner staging: breast B1,armpit hair A2,pubis hair PH5,penis 1 cm*3.5 cm.The surgery incision recovered well and bilateral testis unltrasound show Left volume was 11.59ml and Right was 10.79ml. Adrenal hormone profile shows ACTH 4.090pg/ml, testosterone 7.54nmol/L,17-OHP 0.47nmol/L, serum cortisol is 0.000ug/dl and follow-up is necessary for long-term prognosis.3β-2HSD is a rare type of congenital adrenocortical hyperplasia, accounting for about 5 % of CAH.In 3β-2HSD patients,SW type is usually confirmed in the neonatal period whereas the non-SW type before puberty[The TARTs was firstly described by Wilkins in 1940.Non-typiThe TARTs origin recently was considered that it was related to a more pluripotent steroidogenic cell type that is already present in utero, probably originating from the adrenogonadal primordium or from the urogenital ridge, 12.In aAlthough Claahsen-van has descBesides,fertility loss is deemed as the complication in TARTs cases and always related mechanical obstruction and toxic effect of local adrenal steroids or metabolites derived from adrenal rest tumors.In spiteThe cavity of tunica vaginalis may indicate the severity of TARTs.It is essential to seek for ultrasound examination once suspected scrotal mass occurred. It is necessary to adjust endocrine medicine or adopt surgery when regular and adequate hormone therapy was ineffective or refractory gaint TARTs emerged.Semen analysis were considered an assistant means to preserve fertility in male CAH patients.Additional file 1Supplementary Fig. 1: Gene analysis showed there were two mutations in siblings’s chrosome 1. c.674T > A occurs at chr1:119,964,900 and c.776 C > T occurs at chr1:119,964,798.Additional file 2Supplementary Fig. 2: The pigmented skin in lower limbs and abdomen. Supplementary Fig. 3: (A) Fibrous tissues separate tumor into multi-nodular masses.(B)(C)(D)Images display several molecule results in IHC staining.Method: Olympus BX53 and Axiocam 305 color were used to capture the microscopy images, the horizontal and vertical dpi are 300 in 4 images. We add scale bar to these images by Zen 2.6 (blue edition) without enhancement and merge them intoAdditional file 3Supplementary Fig. 3 by Adobe Illustrator CC 2017.Additional file 4Supplementary table: Table 1–1 and Tables 1 and 2 presents related molecule for indentification in TARTs.


Intrapulmonary hematomas are collections of blood within alveolar and interstitial spaces. They occur mainly following thoracic trauma. Typically, intrapulmonary hematomas without bleeding or infection spontaneously disappear after several weeks to 6 months. In the current case, the patient presented with an intrapulmonary nodule 17 months after a chest injury. The size of the nodule had not changed at 4 months after the first visit. Consequently, the patient was diagnosed with an intrapulmonary hematoma by surgical resection. To our knowledge, there are no previous studies that described the cause of the persistent intrapulmonary hematoma. This study reports the case of a patient who underwent surgical resection of a persistent traumatic intrapulmonary hematoma. •Intrapulmonary hematoma occurs with a chest injury, anticoagulants, thrombocytopenia, and congenital diseases.•Differential diagnoses should include intrapulmonary hematoma when considering medical history.•Patients are generally placed under observation when intrapulmonary hematoma is suspected.•This is the first report on the cause of persistent intrapulmonary hematoma. Typically, they spontaneously disappear from several weeks to 6 months.,2 In the2Chest X-ray findings during a medical checkup of a 70-year-old man showed an abnormal shadow. Chest computed tomography (CT) revealed a nodule on the side of the left lower lobe or posterior mediastinum A. The paContrast-enhanced chest CT of our hospital revealed a nodule in the left lower lobe (S10). The nodule was 27 × 18 × 16 mm in size and was elliptical with well-defined margins. It showed no contrast effect B. FurthePartial resection of the left lower lobe was performed by thoracoscopic surgery. Intrathoracically, the white pleural change was at the left lower lobe. This pleural change was considered as the nodule that was visualized in the image, and a partial resection was performed . The intIn the specimen, a portion of the white pleural change had gross pleural thickening and had cyst-like features located directly below the pleural change. Postoperative pathological findings revealed that the area of the grayish-white capsule showed cyst-like structures and was responsible for the hyalinization of the connective tissue. In high-power fields, the inside of the cyst was filled with red blood cells, fibrin, and hemosiderin-laden macrophage. Considering this, it was our understanding that the nodule was a collection of blood .Fig. 4A,Here were present the case of a patient who had a medical history of chest injury and was diagnosed with traumatic intrapulmonary hematoma.3Intrapulmonary hematomas are collections of blood within the alveolar and interstitial spaces . The mosAccording to previous reports, intrapulmonary hematomas without bleeding or infection usually disappear spontaneously after several weeks to 6 months . Chon reChest X-ray and chest CT of the intrapulmonary hematoma showed a well-circumscribed and inhomogeneous round nodule; however, these findings were not specific . AccordiAlthough the underlying mechanism of expanding hematomas remains unknown, it is often explained though the mechanism of chronic epidural hematomas. In this report, the chronic hematoma shows the formation of a blood-filled capsule caused by a chest trauma. Inflammation under this capsule and the presence of the cellular breakdown products of leukocytes, erythrocytes, platelets, and fibrin cause further damage and bleeding from capillaries. It has been speculated that this mechanism is responsible for the expansion, and not the attenuation, of hematomas . HoweverRegarding the pathology of our case, we confirmed the presence of a cyst-like structure with hyalinized connective tissue around the lesion, along with thick walls consisting of rigid and dense connective tissue, localized directly under the pleura. A large number of capillary blood vessels were present in the hyalinized connective tissue on the distal side of the pleura of the lesion, wherein the lesion was accompanied by the infiltration of inflammatory cells. A clotted mass with an intact fibrin net was present despite the collapse of the red blood cells and the morphology of blood cells inside the lesion. Moreover, we also noted that the red blood cells in the lesion were phagocytosed by the histiocytes as hemosiderin. During our observation of the structure of the capillary blood vessels, we noted that the process of the breakdown of red blood cells into hemosiderin and its subsequent absorption could be attributed to chronic inflammation and immediate bleeding caused by trauma inside the lesion. Conversely, the distribution of the capillary blood vessels inside the rigid and dense connective tissue directly below the pleura was sparse. Therefore, lack of absorption had progressed in this area. The stage at which this rigid and dense connective tissue formed directly below the pleura was pathologically unclear. Thus, it is possible that incidental bleeding occurred directly under the area where the connective tissue was thick, or some other etiology was responsible for the causing the formation of thick connective tissue specifically in the region near the pleura. From these findings, it can be inferred that a balance between bleeding and absorption in the hematoma could be caused the persistence of the hematoma without being absorbed after the trauma. To our knowledge, this is the first reported case to simultaneously show evidence of ongoing bleeding and absorption. We consider that these findings exclude the diagnosis of expanding hematoma.This was a case of an intrapulmonary hematoma that was accidently identified via an imaging examination from a medical checkup. It would not have been possible to eliminate the possibility of an expanding hematoma if we had not excised the lesion. After performing surgical resection of the traumatic intrapulmonary hematoma, the recurrence rate of intrapulmonary hematoma is considered low if the patient does not undergo anticoagulant therapy. Therefore, a long-term follow-up is not needed.4We surgically resected a traumatic intrapulmonary hematoma that did not disappear after a long follow-up period. Pathologically, a balance of bleeding and absorption in the hematoma caused the hematoma to persist without being absorbed after the trauma. Some intrapulmonary hematomas progress in an unusual manner, as observed in this case. It is necessary to consider intrapulmonary hematoma in differential diagnosis by taking into account the patient's medical history. Furthermore, diagnosis through imaging examinations is difficult, and biopsy or surgical resection should be considered.Sachi Kawagishi: Writing - Original Draft, Yuya Kogita: Validation, Itsuko Nakamichi: Resources, Takahiro Matsui: Resources, Toshiteru Tokunaga: Writing - Review & Editing, Supervision.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Emphysematous cholecystitis is a critical differential diagnosis for physicians to consider when evaluating patients with acute abdomen. Patients who are unable to undergo emergency surgery can benefit from percutaneous cholecystostomy. Emphysematous cholecystitis is a critical differential diagnosis for physicians to consider when evaluating patients with acute abdomen. Patients who are unable to undergo emergency surgery can benefit from percutaneous cholecystostomy. A 69‐year‐old male patient presents with a one‐day history of right upper quadrant pain and positive Murphy's sign on examination. Serology revealed leukocytosis (WBC 13.8*10e3/uL), normal liver panel . Past medical history was notable for hypertension, diabetes mellitus, coronary artery disease, chronic systolic heart failure, aortic valve replacement, paroxysmal atrial fibrillation, cerebrovascular accident, and chronic kidney disease stage 4. Ultrasonography showed mildly thickened gall bladder wall, no gall stones, or pericholecystic fluid. Computed abdominal tomography (CT) without contrast revealed emphysematous cholecystitis with typical findings of air in the gall bladder wall and biliary tree .1Patient consent has been obtained for this case report and is available for review upon request. Institutional Review Board, St. Joseph's University Medical Center policies were followed throughout the submission process.The authors declare no competing financial interests.A.M is responsible for the creation, drafting, and writing of manuscript including submission. B.S is responsible for image acquisition, editing, and writing of manuscript. R.M is responsible for final editing, proof reading, and revision of manuscript.The authors declare that all digital photographs in this submission have not been edited, modified, or adulterated in any way.


Spontaneous subdural hematoma rarely presents with a hypervascular or malignant tumor but even less frequently in a benign tumor like meningioma. We encountered a patient with acute subdural hematoma associated with benign meningioma. Here, we report this case along with a review of previous reports, especially focusing on their clinical features and possible bleeding mechanisms.A 53-year-old Asian woman presented with severe headache and progressive neurologic deterioration due to cerebral edema. The patient was submitted to open surgery for evacuation of the subdural hematoma and concurrent tumor removal on the ipsilateral parietal convexity. A hypervascular, encapsulated mass was identified during surgery and completely removed including the adjacent dura mater (Simpson grade 0). The tumor was histologically confirmed as an angiomatous meningioma . Her clinical course was uneventful after surgery.Although meningiomas are commonly benign according to their histological traits, they can lead to spontaneous bleeding and cause neurologically unstable condition. Therefore, meningiomas need to be considered as a cause of spontaneous subdural hematoma if radiologically suspicious, which should be reflected by proper management for a positive outcome.The online version contains supplementary material available at 10.1186/s13256-021-02935-x. Meningioma is one of the most frequently reported intracranial tumors. It accounts for 37.6% of all primary brain tumors and 53.3% of nonmalignant tumors . AlthougHere, we report the case of a middle-aged woman with nontraumatic SDH and cerebral edema originating from a small convexity meningioma. In the wake of this case, we discuss the possible mechanisms of tumor bleeding, as well as the outlines of this condition, with a review of the previously published literature.A 53-year-old Asian woman visited our emergency department complaining of progressive headache and vomiting for 2 days. There was no traumatic event related to her symptoms. She had no previous medical history, and all laboratory tests were within the normal range. Her vital signs were normal. Initial neurologic examination showed alert consciousness and no abnormal neurologic signs. Brain computed tomography (CT) scan revealed a right-sided acute-type SDH with a focal, round-shaped, high-density mass in the right parietal convexity Fig. . Brain mShe underwent an emergency operation. After craniotomy and dura opening, an acute type SDH was noted. The mass lesion identified on MRI was not clearly visible because of thick blood clots. When the dura mater was reflected, the bloody mass lesion inside the dura mater was clearly detached from the cortex without any dissection. This mass measured 1.5 cm in maximal diameter and was covered with fresh blood clots. There was only a small tearing on a cortical vein adhered to the tumor base arachnoid capsule. After gross total removal of the mass and its surrounding dura extending 2 cm from the tumor margin (Simpson grade 0), bleeding was controlled. There was no other active bleeding point, such as a cortical artery or bridging vein in the subdural space. Brain swelling was not excessive, the bone flap was closed, and the wound was approximated layer by layer. In the postoperative course, her neurologic deterioration reverted to normal right after surgery. She was discharged on the 10th postoperative day without any focal neurologic deficit. The follow-up brain MRI taken 6 months later showed no tumor or hemorrhage relapse Fig. .Fig. 3SiHistopathologic examination of the tumor revealed hypercellular components with numerous vascular structures. Mitosis was rare (≤ 2 per ten high-power fields), and the proliferation index (Ki-67) was low, with 3%. No microscopic invasion of the dura or brain tissue was identified, as well as no evidence of malignancy, necrosis, atypia, or anaplasia Fig. . These cSpontaneous SDH is defined as any unusual disruption of cranial vessels within the subdural space without traumatic events . It is let al. reviewed nine cases of repeated bleeding from benign meningiomas and demonstrated that its related mortality of 28–50% is not negligible [Hemorrhagic meningiomas are reported in 1.3–2.4% of all meningioma cases . The blegligible . TherefoSDH is a rare type of hemorrhage related to meningioma, particularly in cases with benign histology. Table et al. noted that peritumoral edema is encountered in 47.1–100.0% of angiomatous meningioma in their review [Angiomatous meningioma is a rare subtype of meningioma. The tumor is characterized by highly vascularized tissues intervening in the background areas of the syncytial pattern of typical meningioma cells , 30. Itsr review . This maThe mechanism of SDH associated with benign meningioma is still obscure. Previous reports suggested several hypothetic mechanisms based on intraoperative findings or pathologic examinations. They include (1) rupture of a weak point of the vessel wall in the distended feeding artery with tumor growth; (2) disruption of abnormally developed vessels in the tumor, causing intratumoral hemorrhage or necrosis; (3) histochemical changes by vasoactive substances released by the tumor itself, consequently leading to neovascularization or forming a neomembrane such as in chronic SDH; and (4) potential friability of the bridging vessels or subdural veins stretched by the tumor mass and, thus, susceptibility to minor trauma , 7, 15. According to Table Benign convexity meningiomas rarely develop an SDH, and their clinical progress can be worse than expected. Therefore, a meningioma should be fully suspected as the cause of a spontaneous SDH in cases with no vascular abnormalities or coagulopathies. In addition, early diagnosis and proper management including hematoma evacuation and tumor removal are recommended to alleviate a patient’s neurologic condition and to improve the prognosis. Additional file 1. Detailed characteristics of World Health Organization (WHO) grade I meningiomas presenting with subdural hematoma.


Despite improvements in imaging modalities, causative lead points in adult intussusception may be difficult to diagnose. Such lead points can be malignant, causing recurrence or metastases if left unresected. We describe a case of transient adult jejunojejunal intussusception, in which intraoperative endoscopy was used to confirm the absence of a lead point. A 39-year-old woman with a history of laparoscopic oophorectomy presented with epigastric pain, nausea, and vomiting. Contrast computed tomography revealed jejunojejunal intussusception, with no visible lead point. Spontaneous reduction was confirmed during exploratory laparoscopy. After lysis of adhesions, intraoperative peroral jejunoscopy was performed with the surgeons' assistance. Endoscopy confirmed the absence of tumor, and bowel resection was avoided. No recurrence has been observed during 24 months of follow-up. Intraoperative endoscopy may provide additional reassurance for the absence of a lead point in cases where preoperative enteroscopy cannot be performed and no lead points can be identified on imaging. While intussusceptions in children are commonly idiopathic, adult intussusceptions (AI) generally have a causative lead point. Enteric intussusceptions, the most common type accounting for about 50% of AIs, have been reported to result from malignant tumors in 22.5% of cases, with metastatic carcinoma being the most common malignant lead point . On the One type of AI, classified as idiopathic by some authors, is caused by adhesions resulting from prior surgery –3. TrulyAlthough not always possible preoperatively, enteroscopy offers an alternative to confirm the absence of a lead point without bowel resection. Herein, we report a case of intraoperative endoscopy performed on a patient with jejunojejunal AI which demonstrated the absence of tumor in the jejunum, providing additional reassurance that bowel resection could be avoided.A 39-year-old woman presented with epigastric pain, intermittent nausea, frequent vomiting, and loss of appetite over the last seven days. She denied weight loss. She could pass gas but had not passed stool over the last four days. She was able to tolerate a full meal the night before presenting to the hospital, but nausea and vomiting had resumed within several hours.Her medical history was significant only for laparoscopic oophorectomy for a left ovarian cyst almost 20 years prior. She was taking no medications, herbal remedies, or nutritional supplements. She admitted to chronic alcohol abuse with frequent visits to the emergency department due to alcohol intoxication, but had never smoked cigarettes. She denied any recent sexual contact, overseas travel, raw food ingestion, or sick contacts.Upon presentation, the patient appeared to be in moderate distress. Her respiratory rate was 24 breaths per minute, but vital signs were otherwise stable. She complained of discomfort on palpation of the epigastric region. The upper abdomen was soft but mildly distended. No mass was palpated. Small scars from previous laparoscopy were noted.Laboratory results were only remarkable for a mildly elevated C-reactive protein of 0.44 mg/dL. Esophagogastroduodenoscopy (EGD) performed 20 hours after the patient's last meal revealed a mildly distended stomach with significant food residue in the esophagus and stomach . The patDespite the patient's ability to pass gas, an emergency computed tomography (CT) scan was conducted to rule out small bowel obstruction. CT without contract was largely unremarkable, with no visible signs of tumor or bowel obstruction . HoweverWhile the possibility of spontaneous reduction was explained, the patient wished to undergo exploratory laparoscopy due to the severity of her symptoms. The surgeons also agreed to exploratory laparoscopy in light of the severe obstructive symptoms, surgical history with possible adhesions, and possible recurrence if left untreated. Consent for intraoperative endoscopy was also obtained to evaluate the jejunum for a possible lead point, as the patient was not in a condition to undergo preoperative enteroscopy.Exploratory laparoscopy was performed the next day. Severe jejunal hyperactivity was observed intermittently throughout the laparoscopy. However, no intussusception was observed, suggesting spontaneous reduction. Tumors and segmental edema in the proximal jejunum were also notably absent. Adhesions from previous laparoscopic oophorectomy were observed near a port placed in the right lower quadrant . While aIntraoperative peroral jejunoscopy was performed with a long colonoscope  and carbon dioxide insufflation. A thorough laparoscopic exploration was completed prior to commencing intraoperative endoscopy, as endoscopic insufflation would hinder the laparoscopic view. The surgeons used laparoscopic grasping forceps to apply gentle pressure to the stomach to facilitate scope insertion . When thThe patient experienced complete resolution of her symptoms after the surgery. The postsurgical course was uneventful and the patient was discharged two days later, with instructions to stop drinking alcohol. No recurrence was observed during 24 months of follow-up.AI presents two problems for the patient: symptoms relating to bowel obstruction and a potentially malignant lead point.AI can be difficult to diagnose due to its rarity and the chronic, nonspecific nature of its symptoms , 4. In gWhile symptoms can be relieved by reduction or bowel resection, recurrence has been reported in about 6.5% of all AI cases . This fiTransient intussusceptions with spontaneous reduction are very common in children as they are generally idiopathic in nature, particularly when the length of the intussusception is less than 3 cm , 19. SimAs the adhesions observed during laparoscopy were distant from the site of intussusception, we suspect that bowel hyperactivity due to chronic alcoholism played a role in the pathogenesis of AI in our case. The effects of alcohol on small bowel motility depend on the alcohol concentration of consumed beverages and chronicity of alcohol use, with chronic consumption of large doses of alcohol accelerating small bowel transit , 22. TheBoth antegrade enteroscopy and retrograde enteroscopy have been used to diagnose various types of lead points including gastrointestinal stromal tumor, inverted Meckel's diverticulum, inflammatory fibroid polyp, Peutz–Jeghers syndrome, heterotopic pancreatic mass, malignant melanoma, and mass-forming fibrogranulation from a healed ulcer –31. PreoEndoscopy has been used in various surgical procedures such as laparoscopic endoscopic cooperative surgery, confirmation of anastomoses during gastrointestinal surgery, and in exploratory laparotomy for obscure gastrointestinal bleeding –34. IntrReports of intraoperative endoscopy in the setting of AI are mainly limited to Peutz–Jeghers syndrome , 39. TheInsertion of the long colonoscope could be achieved without fluoroscopy with the surgeons' assistance. Although surgeons' hands in a laparotomy would be ideal, grasping forceps during laparoscopy provided helpful resistance during scope insertion in our case. The camera light clearly showed the planned destination for the enteroscopy in an otherwise uniform bowel. Intubation under general anesthesia allowed for a painless procedure with no risk of aspiration.In conclusion, we report a case of transient jejunojejunal AI in which the absence of tumor was confirmed by intraoperative endoscopy. Intraoperative endoscopy may be helpful to assess the need for small bowel resection when no lead point can be identified on preoperative imaging and preoperative enteroscopy cannot be performed.


Background: Ovarian vein thrombosis (OVT) commonly occurs during the peripartum and postpartum period. However, few cases of idiopathic OVT unrelated to pregnancy have been described.Case report: We report a case of a previously healthy, 32-year-old female who presented with chronic right-sided abdominal pain. Abdominal and pelvic gadolinium-enhanced MRI showed a right OVT. The patient was not in the peripartum or postpartum period. Thrombophilia test results were negative, and no risk factors for thrombosis were noted. The patient received warfarin for 6 months, with resolution of her symptoms.Conclusion: The presented case emphasizes the significance of considering OVT as a cause of unexplained abdominal pain in a young female. We describe a rare case of idiopathic OVT with a unique presentation. Diagnosis is confirmed using conventional radiological imaging, such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Treatment of OVT includes anticoagulation therapy. In this report, we present a rare case of idiopathic OVT in a young female without risk factors for thrombosis. Informed consent for publication of this case was obtained from the patient.Ovarian vein thrombosis (OVT) is a rare puerperal complications, with an incidence of about 1/600–1/2000 deliveries. It commonly occurs in the postpartum period. However, few cases have been reported in non-pregnant patients.A previously healthy 32-year-old Egyptian lady presented to the outpatient medical clinic with a 3-month history of right-sided abdominal pain exacerbated by movement and relieved with over-the-counter analgesics. The pain was related to food intake. She described the pain as stabbing in nature and radiating to the back. She denied any history of melena, dysphagia, weight loss, anorexia, nausea, and vomiting as well as history of fever or night sweats. She did not complain of vaginal discharge or menstrual abnormalities.She is a nonsmoker and denied any personal or family history of venous thromboembolism. Her gynecological history was remarkable for five pregnancies. She had normal vaginal deliveries except for the last one, which required an emergency Cesarean section at 36 weeks and 5 days of gestation due to placenta previa type III. One month after delivery, the patient was started on desogestrel  for contraception, which she continued for 2 years. Her menstrual period was irregular, and the last withdrawal bleeding was 2 weeks prior to clinic visit.During the initial clinic visit, her vital signs were within normal limits . Abdominal examination was significant for a mild tenderness in the right upper quadrant. Bowel sounds were noted.Initial laboratory findings, including complete blood count, renal parameters, and electrolytes, liver function, lipase, and amylase levels, were within normal limits. Beta-hCG was negative. Initial differentials included cholecystitis, hepatitis, or hepatic abscess. Thrombosis of the portal vein is a possible differential diagnosis; however, in the absence of significant risk factors in the patient's history, further evaluation by ultrasound of the abdomen is required.Abdominal ultrasound showed multiple hyperechoic focal lesions, the largest measuring 15 × 15 mm in the right hepatic lobe, suggestive of hemangiomas, indicating further evaluation by abdominal gadolinium-enhanced MRI, which confirmed hepatic hemangiomas; additionally, right OVT was suspected. Therefore, pelvic MRI with gadolinium-based contrast was requested, which revealed a prominent right ovarian vein measuring 8 mm in diameter with loss of flow void and persistent central nonenhancement with mild peripheral enhancement, indicating partial thrombosis of the right ovarian vein. Furthermore, the left ovarian vein was patent. Mild pelvic congestion and a small follicular cyst in the right ovary was noted , 1B.Further laboratory investigations were performed to evaluate the underlying cause of the thrombosis, including factor V Leiden mutation, ANA, lupus anticoagulant, anticardiolipin antibody, beta-2 microglobulin, and JAK2 mutation, which were all negative . Few thr28 At her 6-month follow-up, she reported significant improvement of the abdominal pain. The patient was lost to follow-up as she traveled to her home country.The patient was started on anticoagulation (warfarin) for 6 months. The dose of warfarin was adjusted upon regular follow-ups in the anticoagulation clinic to maintain a target INR of 2–3. She was referred to an obstetrician and was advised to use barrier methods for contraception. Moreover, she was advised to avoid hormonal contraceptives due to the recent ovarian thrombosis and multiple hemangioma finding as oral contraceptives increase the size of hepatic hemangiomas and predispose transformation to malignant hepatomas.4 The incidence of postpartum OVT is 1/600–1/2000 deliveries; the estimated incidence post-vaginal delivery is 0.18% and post Caesarian section is 2%.6 It was found that most OVT cases are diagnosed in the postpartum period due to the rise in estrogen hormone, causing a hypercoagulable status, or gravid uterine mechanical compression to the ovarian vein.5 Moreover, OVT may occur immediately after major pelvic surgeries.7OVT is a rare but life-threatening complication that usually occurs in the intrapartum or postpartum period.8 Moreover, OVT is commonly diagnosed within a few weeks postpartum.1 Symptomatic OVT is observed in 0.01%–0.05% of deliveries, mainly after Cesarean surgeries.1 Symptoms usually appear within 10 days post-delivery; however, it can present up to 4 weeks postpartum.3Most patients with underlying OVT usually present with fever, pelvic pain, abdominal mass, or abdominal pain.9In contrast, OVT cases may be asymptomatic. Few cases were detected during screening MRI, whereas others were reported in a setting of underlying malignancies, pelvic inflammatory disease (PID), or post-major pelvic surgeries.3 In the present case, the diagnosis of idiopathic OVT was established after ruling out hypercoagulable states, such as recent delivery, malignancies, major surgeries, and PID.1Previous studies showed that 50% of patients with OVT have other risk factors, such as prothrombotic conditions, including protein S deficiency, factor V Leiden mutation, and antiphospholipid syndrome.11There is a threefold increase risk of OVT in the peripartum and postpartum period due to reduced blood flow in the vein and stasis. Thrombosis tends to occur in the right gonadal vein due to its longer length, multiple incompetent valves, and the gravid uterine dextrorotation.3, and various studies have shown different results in the sensitivity and specificity of imaging modalities. For example, magnetic resonance (MR) angiography was found to have 100% specificity and 92% sensitivity in establishing an OVT diagnosis.10Diagnosing OVT can be challenging, and laparotomy remains the gold standard in its diagnosis. Several studies have explored the role of different imaging methods as diagnostic tools13 Doppler ultrasound is commonly used due to its easy accessibility, lack of risk of radiation, and low cost. It has a sensitivity of 56% and a specificity of 42%.12 However, it is the least sensitive modality for the detection of OVT, as it cannot scan the whole length of the ovarian vein.13 Moreover, Doppler ultrasound is known to be operator-dependent, and bowel gases often result in poor-quality images.14CT scan with IV contrast has 78% and 62% sensitivity and specificity, respectively. CT scan is preferred over MR as it is time and cost-effective.3 Haris et al. reported that the mortality of PE as a result of untreated OVT is around 4% (6).In rare cases, OVT can lead to lethal complications, including thrombus migration into the inferior vena cava (IVC), progression to pulmonary embolism (PE), and development of septic thrombophlebitis.15 However, most of the literature supports that OVT should be considered and managed as lower-extremity deep vein thrombosis (DVT) with regard to anticoagulation.3 Previous studies recommended treating thrombophlebitis-induced OVT with warfarin along with LMWH bridging for 7–10 days, combined with broad-spectrum antibiotics. Furthermore, when thrombus extends to the renal vein or IVC, warfarin should be continued (with LMWH bridging) for 3–6 months.3Moreover, the treatment of OVT remains debatable. There is no consensus in the international guidelines regarding the initiation, choice, and duration of anticoagulation. Few studies suggested conservative management, especially in incidentally detected thrombi in the postoperative period, unless complicated.16 Additionally, patients with unstable thrombosis may be subject for surgical options.2Another area of controversy is surgical intervention in patients with OVT. Surgical options include IVC filter insertion or surgical ligation of the vein to prevent the extension of the thrombus. These are reserved for patients who failed or are unable to tolerate medical treatment.Our patient was diagnosed with idiopathic ovarian thrombosis. Her thrombophilia test findings were unremarkable, and she was not postpartum. The use of desogestrel (a progestin-only contraceptive) is less likely to contribute to the risk of developing thrombosis. Based on observational studies, there was no association between progestin-only pills and increased risk of venous thromboembolism (VTE) in the general population. She was started on LMWH bridging, followed by warfarin for 6 months. She was then referred to the hematology clinic, where no risk factors for thrombosis were identified. Her abdominal pain subsided, and she was well during the follow-up period.OVT is a common complication in the puerperal period; however, few cases have described idiopathic OVT in non-pregnant patients, and diagnosis and treatment in the latter group of patients remains controversial. The present case reveals the difficulty of the clinical diagnosis of OVT. It highlights the significance of OVT as a possible differential diagnosis in a non-pregnant female presenting with chronic abdominal pain.OVT: Ovarian vein thrombosisVTE: Venous thromboembolismPE: Pulmonary embolismDVT: Deep vein thrombosisLMWH: Low-molecular-weight heparinCT: Computed tomographyMRI: Magnetic resonance imagingPID: Pelvic inflammatorydiseaseThe authors would like to acknowledge Dr. Akram Twair (from the Radiology Department) for detecting the ovarian thrombus and helping in the diagnosis.None.The authors have no conflict of interest to declare.SDA and SS: manuscript writing and literature review; FSAM: diagnostic image interpretation and reporting; MA: team supervisor and mentor, as well as manuscript review.Informed consent was obtained from the patient for the publication of this case report and any accompanying images.The case was approved by Medical Research Center at Hamad Medical Corporation. (MRC # 04–20–100).


Primary pulmonary Ewing sarcoma can present as a massive mass in the left hemithorax covering the entire lung and can press the pulmonary artery and cause a significant mediastinal shift. Primary pulmonary Ewing sarcoma can present as a massive mass in the left hemithorax covering the entire lung and can press the pulmonary artery and cause a significant mediastinal shift. Rarely, it may arise from soft tissue in the chest wall. We present a 16‐year‐old male patient with a large mass in the left hemothorax covering the entire lung and pressing the pulmonary artery. Histopathology confirmed the mass as Ewing's sarcoma.A 16‐year‐old male patient presented with a one‐month history of progressively increasing nocturnal cough and dyspnea. Physical examination was normal apart from supplemental oxygen requirement (2 lpm). A chest X‐ray revealed a complete whiteout of the left hemithorax. A CT‐scan revealed an 18‐cm mediastinal mass with pleural effusion, pressing the pulmonary artery and causing a mediastinal shift to the right , multiple cases of pulmonary ES are reported to date. Tumor sizes are reported to range between 4 and 9 cm.2Primary pulmonary Ewing Sarcoma can present as a massive lung mass with compressive signs and symptoms. Due to a poor prognosis, rapid identification followed by surgery and chemotherapy can aid in mortality reduction.None of the authors have any conflict of interest to disclose.FA involved in conceptualization, methodology, literature review, manuscript writing, image selection, and arrangement, review, and revisions in the final manuscript. AM and MA involved in literature review and manuscript writing. SM: involved in radiology part of the image case, figure, and legend provision. AZ: involved in supervision, case identification, review, and revisions in the final manuscript. All authors reviewed and approved the final version of the manuscript.Written consent was taken from the patient for the brief clinical case and accompanying images before submission. The clinical image case was approved by the Medical Research Centre (MRC), Qatar, before submission.Written informed consent was obtained from the patient for publication of this case report and accompanying images.


Fistulae between the colon or the small intestine and the uterus are extremely rare as the uterus is a thick, muscular organ. Here, we present the case of a 74-year-old female presenting to our surgical department because of fecal vaginal discharge for the past few months, which proved to be caused by a combined colouterine and jejunouterine fistula due to chronic diverticulitis. Total abdominal hysterectomy with bilateral oophorectomy with en bloc resection of part of the jejunum and the sigmoid colon and primary anastomoses were performed. This case represents an unusual type of diverticulitis complication and aims to point out the diagnostic and therapeutic issues of such a rare medical condition. Diverticulosis is one of the most common colonic pathologies. It affects, mostly, those who are living in developed countries, and its incidence is well known to increase with age. However, the incidence of diverticular disease has, recently, been increasing in Third-World countries . Divertist postoperative day.A 74-year-old female was referred to our department of surgery with malodorous fecal vaginal discharge that had lasted several weeks. Medical history included multiple episodes of acute diverticulitis and dementia. She had no abdominal pain or fever. Upon admission, her laboratory tests were within the normal range. Pelvic examination revealed an atrophied vagina and malodorous yellowish vaginal discharge. A colovaginal fistula, secondary to diverticular disease, was suspected as it is the most common type of fistula between the gastrointestinal and female reproductive system. Cultures of the vaginal discharge were sent. Nil per os, total parenteral nutrition, and intravenous antibiotic therapy with ciprofloxacin and metronidazole were applied to the patient until a definitive diagnosis would be made. An abdominal computed tomography (CT) showed multiple diverticula and findings indicative of chronic diverticulitis, such as thickening of the wall of the sigmoid colon and pericolic fat stranding Figures  and 2. AFistula creation between the gastrointestinal tract and the uterus is rare. The fistula is usually found between the fundus of the uterus and loops of the sigmoid colon or small bowel . In caseMany imaging modalities have been suggested for establishing the diagnosis of a colouterine or jejunouterine fistula. Vaginal or cervical cultures will determine the source of vaginal discharge and will be useful for selecting the appropriate antibiotic therapy. The imaging modality for diverticular fistulae has been contrast radiology, either rectally or vaginally. Computed tomography (CT) may reveal evidence of diverticulitis and communication between the uterus and the colon, but it may fail to demonstrate the fistulous tract. A multidetector computed tomography (MDCT) has been used to provide better visualisation of the fistula, but it is associated with great radiation. Magnetic resonance imaging (MRI) is a more accurate diagnostic tool, able to identify fistulae, and demonstrate the degree of pericolic inflammation, especially in T1-weighted images. In our case, MRI was the effective modality for diagnosis as it was the only imaging technique indicating the colouterine fistula. The charcoal test depends on demonstrating the passage of orally administered activated charcoal from the cervical os at pelvic examination on the next day. A colonoscopy may be useful in the diagnosis of diverticulosis, but it is not very helpful in the detection of fistulae. Finally, endovaginal ultrasonography and sonohysterography using a contrast medium could be used to visualise both the fistula tract and the uterine wall and colon .Surgical management is the treatment of choice, in most cases. Many surgical approaches have been suggested. Hartmann procedure with hysterectomy, transverse colostomy followed by hysterectomy and closure of the fistula without bowel resection, and an en bloc resection of the uterus and the colon or small bowel are several examples . HystereFistulae between the uterus and the bowel are very rare complications of diverticulitis. They should be suspected in case of malodorous discharge from the vagina so that the appropriate diagnostic tests may be conducted and the best therapeutic options may be applied. Accurate diagnosis is the key to prompt treatment of this very rare condition.


Pancreaticoduodenal artery aneurysms (PDAAs) are rare visceral aneurysms, and prompt intervention/treatment of all PDAAs is recommended at the time of diagnosis to avoid rupture of aneurysms. Herein, we report two cases of PDAA caused by the median arcuate ligament syndrome, treated with surgical revascularization by aortosplenic bypass followed by coil embolization.Case 1 A 54-year-old woman presented with a chief complaint of severe epigastralgia and was diagnosed with two large fusiform inferior PDAAs and celiac axis occlusion. To preserve the blood flow of the pancreatic head, duodenum, liver, and spleen, we performed elective surgery to release the MAL along with aortosplenic bypass. At 6 days postoperatively, transcatheter arterial embolization was performed. At the 8-year 6-month follow-up observation, no recurrent perfusion of the embolized PDAAs or rupture had occurred, including the non-embolized small PDAA, and the bypass graft had excellent patency.Case 2 A 39-year-old man who had been in good health was found to have a PDAA with celiac stenosis during a medical checkup. Computed tomography and superior mesenteric arteriography showed severe celiac axis stenosis and a markedly dilated pancreatic arcade with a large saccular PDAA. To preserve the blood flow of the pancreatic arcade, we performed elective surgery to release the MAL along with aortosplenic bypass. At 9 days postoperatively, transcatheter arterial embolization was performed. At the 6-year 7-month follow-up observation, no recurrent perfusion or rupture of the PDAA had occurred, and the bypass graft had excellent patency.Combined treatment with bypass surgery and coil embolization can be an effective option for the treatment of PDAAs associated with celiac axis occlusion or severe stenosis. Pancreaticoduodenal artery aneurysms (PDAAs) are rare, accounting for about 2% of all visceral aneurysms . PDAAs aA 54-year-old woman presented with a chief complaint of severe epigastralgia. She had no history of pancreatitis, abdominal trauma, or connective tissue disorders. A computed tomography (CT) scan and angiography of the superior mesenteric artery (SMA) showed celiac axis occlusion and a markedly dilated pancreatic arcade with two large fusiform inferior PDAAs Fig. a–f. The Transcatheter arterial embolization (TAE) was considered as the first treatment option. However, we hesitated to perform TAE because (1) coil packing was necessary for complete embolization of these fusiform PDAAs, and (2) complete embolization of the PDAAs was considered highly likely to result in marked diminishment of blood flow of the pancreatic head, duodenum, liver, and spleen because of the celiac axis occlusion. In addition, the aneurysm was located around the pancreatic head. Surgical treatment would require pancreaticoduodenectomy with arterial bypass for revascularization of the celiac territory, but this would have been highly invasive.Therefore, we performed elective surgery to restore the normal arterial flow of the celiac axis. Intraoperatively, the general exploration findings were normal, and no hematoma was present. After the MAL release, the blood flow of the celiac axis was not restored Fig. a. TherefAt 6 days postoperatively, a CT scan and angiography via bypass Fig. a and SMATherefore, TAE of the two inferior PDAAs was performed. Proximal and distal embolization of the inferior PDA combined with packing of the aneurysms was performed Fig. a, b. In A 39-year-old man who had been in good health was found to have a PDAA with celiac stenosis during a medical checkup. A CT scan and superior mesenteric arteriography showed severe celiac axis stenosis Fig. a and a mAt 9 days postoperatively, antegrade flow of the hepatic and splenic arteries via bypass and decreased retrograde flow of the PDA via the SMA were confirmed by CT Fig. e and angPDAAs are very rare, accounting for only 2% of all visceral aneurysms . Unlike The most frequent cause of PDAAs is pancreatitis 31%), followed by celiac axis stenosis (27%), atherosclerosis 24%), congenital disorders (13%), trauma (4%), and mycotic infections (4%) [1%, follo%, congenThe therapeutic strategies for PDAAs involving the MAL must include both securement of the blood flow of the celiac arterial system and treatment of the aneurysm. The treatment methods used to secure the blood flow include both surgical procedures (MAL release and/or bypass surgery) and endovascular therapy  –12. TreaEight cases of combined bypass surgery and TAE for PDAAs have been reported to date , 9–12. TCombined treatment with bypass surgery and coil embolization can be an effective option for the treatment of PDAAs associated with celiac axis occlusion or severe stenosis. Further follow-up is necessary to clarify the efficacy of our combination treatment in terms of prevention of PDAA rupture and long-term patency of the bypass graft.


Foot pain is a prevalent musculoskeletal complaint with plantar fasciitis being one of the most common underlying etiologies. Diagnostic imaging studies are rarely performed for patients with plantar fasciitis. We report the case of a 34-year-old woman with a six-month history of left heel pain that was worsened by prolonged standing and walking. She was diagnosed as having plantar fasciitis. Considering the lack of clinical improvement on conservative measures, the patient underwent a plain radiograph, which demonstrated a geographic radiolucent lesion in the calcaneus with well-defined non-sclerotic margins. Subsequently, a computed tomography scan re-demonstrated the lesion as having a fat-attenuation appearance that was classic of lipoma. The patient underwent surgical excision of the tumor and the histopathological examination of the specimen revealed spindle cell lipoma. The patient had complete resolution of the pain following the surgery. Intraosseous lipoma is a very rare benign primary bone tumor. The case demonstrated that the intraosseous lipoma may have similar clinical features to plantar fasciitis. Hence, physicians should keep a high index of suspicion for the alternate diagnoses of plantar fasciitis in patients who do not exhibit any clinical improvement despite a prolonged period of conservative management. Musculoskeletal complaints are very common and are one of the most frequent reasons for general practice visits. It is estimated that up to one-third of visits to primary care centers are related to musculoskeletal disorders . Heel paA 34-year-old woman presented to the family and community medicine clinic with a complaint of left heel pain for six months duration. She described the pain as sharp in nature. The pain had gradual onset and it had been increasing in severity. The pain was aggravated by standing or walking for a prolonged period. The pain was not associated with a history of sensory or motor weakness. She did not have any pain in the right foot. The patient reported no history of trauma-related to her pain. There was no history of morning stiffness in her heels. The patient did not complain of any joint pain, skin rash, or muscle weakness, fever, or weight loss.The patient visited multiple orthopedic clinics previously. She was diagnosed as having plantar fasciitis. The condition was attributed to her obesity. The impact of obesity on plantar fasciitis was discussed. She was advised to undergo lifestyle modification to reduce her weight. She was offered symptomatic treatment with non-steroidal anti-inflammatory medications. However, these analgesics gave no significant improvement. She also underwent several sessions of physiotherapy with stretching exercise therapy.The past medical history was remarkable for polycystic ovarian syndrome for which she was taking metformin 500 mg daily. No history of previous surgical intervention. The patient was a non-smoker and had no history of alcohol consumption. She worked as a computer science professor. No history of rheumatological diseases in the family.Upon examination, the patient was obese and had a body mass index of 37.2 kg/m2. There was no tenderness over the heel. No evidence of soft tissue inflammation in the left foot. Laboratory investigations revealed normal hematological and biochemical parameters. Autoimmune antibodies panels, including antinuclear antibody, anti-dsDNA, anti-Smith, anti-Ro, and anti-La, were negative.Considering the chronicity of the pain and unresponsiveness to non-surgical treatments, the patient underwent a plain radiograph for the ankle and heel. The radiograph demonstrated a geographic radiolucent lesion in the anterior part of the calcaneus with well-defined non-sclerotic margins Figure . The radSubsequently, the patient underwent surgical intervention and the tissue on the target area was removed and replaced by bone grafting. Histopathological examination of the lesion showed mature adipose cells with interposed uniform spindle cells conferring the diagnosis of spindle cell lipoma Figure . The patWe reported a rare case of osseous lipoma of the calcaneus presenting with chronic heel pain that was mistakenly diagnosed as plantar fasciitis. Intraosseous lipoma is a very rare benign bone tumor accounting for less than 1 per 1000 of all primary bone tumors . Such tuThe pathogenesis of intraosseous lipoma remains unclear. It is believed that intraosseous lipoma is a true benign neoplasm of the yellow marrow of the bone. However, other hypotheses suggest that intraosseous lipoma arises from fat metaplasia from previous trauma or infection . SpindleImaging studies can make the diagnosis of intraosseous lipoma with high accuracy. Radiographs show a lucent intramedullary lesion that may be surrounded by a thin sclerotic rim. The lesion may have central calcification and mild cortical expansion . A compuIntraosseous lipoma is a very rare benign primary bone tumor. The case demonstrated that the intraosseous lipoma may have similar clinical features to plantar fasciitis. Hence, physicians should keep a high index of suspicion for the alternate diagnoses of plantar fasciitis in patients who do not exhibit any clinical improvement despite a prolonged period of conservative management. Surgical excision of the tumor is curative and results in complete resolution of the pain.


Paragangliomas are a rare form of highly vascularized tumors that originate from paraganglia Baysal . In the head and neck PGL arise primarily in four distinct areas: vagal, middle ear, and larynx and more frequently carotid bifurcation. Imaging evaluations include sonography, color Doppler, US-elastosonography and contrast-enhanced ultrasound (CEUS). Additionally, Computed Tomography, Magnetic Resonance Imaging (MRI) as well as digital subtraction angiography can be performed Stoeckli et al. . We present herein a case of a rare bilateral carotid body tumor assessed with multiparametric ultrasound evaluation, including CEUS and US-elastography. Head and neck paragangliomas (HNPGL) are a group of slow-growing hypervascular tumors associated with the paraganglion system , occurriFamilial paraganglioma syndrome type 1 (FPGL1) is due to mutation in SDHD gene and it is characterized by the development of PGLs, in the most of cases localized in head and neck region. PGLs normally present after the age of 30 years . ClinicaThe most recent EFSUMB guideline describes USE  as a tecHistorically, angiography was the “gold standard” diagnostic procedure for CBTs to confirm the diagnosis and provide accurate delineation of the vascular supply. However, with improvements in high-resolution imaging, cross-sectional imaging (such as CT angiography or MR angiography) is the preferred modality for surgical planning of tumor resection because it best defines the relationship of the tumor with the artery bifurcation and the likely location of the cranial nerves. MRI does not use ionizing radiation, and the accuracy of MRI is higher in comparison to that of CT in many cases.Although, CEUS has a recognized role for different organs –11. TherIndeed, CEUS appears a useful and safe tool for identifying CBTs and evaluating intratumoral microperfusion at high spatial and temporal resolutions in real-time, although it should be taken in account the main limitation that is the lack of panoramicity. In the daily clinical routine CEUS can be used to easily monitor therapy success and efficiency after embolization and seems to be a viable option with superior benefits compared to standard Color-Doppler for follow-up of these patients. Additionally, CEUS can be performed on almost every patient because of the limited contraindications of the used contrast agent. Patients with reduced renal function can particularly benefit from this method . In the In conclusion CEUS may be implemented in the future diagnostic work-up and follow-up of CBT patients in addition to conventional ultrasound, CT, MRI and digital substraction angiography (DSA). Therefore, further multi-center studies are encouraged to confirm the clinical use of these techniques on CBTs, as limited evidence is still available.


Inverted Meckel’s diverticulum refers to the condition in which the diverticulum inverts on itself. The reasons for such an inversion are poorly understood due to the rarity of the condition. We present a case of inverted Meckel’s diverticulum, an uncommon finding, as a cause of recurrent intussusception.A 30-year old Indian woman presented with complaints of pain in the central abdomen for 3 days, accompanied with vomiting and loose stools. Computed tomography images were suggestive of intussusception with intestinal obstruction. Intra-operative findings were suggestive of an intussuscepted segment of ileum measuring 10 cm in length, proximal to ileocecal junction. Ileo–ileal anastomosis was performed after appropriate resection. Upon opening the specimen, we were surprised to find an inverted Meckel diverticulum with lipoma at one end causing the intussusception. The patient made an uneventful recovery and was discharged after 5 days.The reasons for inversion include abnormal peristalsis around the diverticulum and non-fixity of the diverticulum itself. The inverted diverticulum itself can cause luminal compromise and acts as a lead point for intussusception leading to obstruction. Computed tomography remains the diagnostic tool of choice for identifying intestinal obstruction and intussusception. Although pathological signs, such as lipoma, can be identified, the identification of any inversion will require a proficient radiologist. Inverted Meckel’s diverticulum is a rare condition which is difficult to diagnose preoperatively. Treatment is surgical, whether diagnosed pre-operatively or intra-operatively, and includes segmental resection and anastomosis. This uncommon condition should be noted as one-off differential diagnosis for intussusception and intestinal obstruction. Meckel’s diverticulum, although a common anomaly of the gastrointestinal tract, rarely presents with symptoms. Symptoms, when present, signify an underlying disease process, suggesting complications of Meckel’s diverticulum, such as intestinal obstruction, intussusception, bleeding, and inflammation , 2. An i2 of 98% at room air. The abdomen was soft, there was mild central distension, and bowel sounds were increased. Laboratory investigations were essentially normal. The patient had a history of two similar episodes over the preceding 6 months, both of which resolved spontaneously following treatment with a conservative regimen. Abdomen X-ray was suggestive of dilated jejunal and proximal ileal loops. In view of the previous two similar episodes, a computed tomography (CT) was done, with the results suggestive of an intraluminal fatty mass surrounded by a thick collar of soft tissue attenuation consistent with the target sign suggesting intussusception in the distal small bowel, along with dilated proximal small bowel loops. (Figs. A 30-year old Indian woman presented with complaints of pain in the central abdomen for 3 days, with vomiting and loose stools. On examination, she had a pulse rate of 84/min, blood pressure of 110/84 mmHg, respiration rate of 15 breaths per minute and SpOMeckel’s diverticulum is a remnant of the vitelline duct , and it An inverted Meckel’s diverticulum refers to the condition in which the diverticulum inverts on itself. The plausible causal factor of this inversion is an abnormal peristalsis in the segment of bowel just proximal to the diverticulum . In addiThis condition may present with pain, bleeding, luminal compromise, and/or intussusception. The CT scan of a patient with Meckel’s diverticulum may show an air- or fluid-filled blind ending pouch from the anti-mesenteric surface of the distal ileum, whereas that of an inverted Meckel’s diverticulum appears as an intraluminal mass surrounded by a thick collar of enhancing soft tissue due to the entrapped perienteric fatty tissue within the inverted serosal side of the diverticulum . A CT scOur patient presented with complaints of central abdominal pain and features of bowel obstruction for the third time in the last 6 months. CT imaging showed features of an intraluminal mass with a thick collar of surrounding soft tissue density and target sign on the CT scan, corresponding well with the described findings. The suspected mass within was identified as lipoma due to its classic homogenous low attenuation appearance on the CT scan with a minimal internal soft tissue component . HoweverSurgery remains the mainstay of treatment of adult intussusception due to any cause. The surgical procedure of choice remains segmental resection followed by primary anastomosis . In our Inverted Meckel’s diverticulum is an uncommon condition which results due to abnormal peristalsis around the diverticulum and non-fixity of the diverticulum itself. The aim of this case report is to alert surgeons to this rare clinical entity which is encountered only on the surgical table. Pre-operative diagnosis of inverted Meckel’s diverticulum is a difficult due to overlapping clinical and imaging features. Treatment is surgical, whether diagnosed pre-operatively or intra-operatively, and includes segmental resection and anastomosis.