Petrified ears is an uncommon clinical entity. It describes auricular cartilage hardening, due usually to ectopic calcification or, less commonly, ossification. The most common causes are frostbite and mechanical trauma. However, endocrinopathies have also been reported to cause ectopic calcium deposition through an unknown mechanism. Addison’s disease is the systemic disease most frequently associated, but the exact pathogenesis remains unclear. Patients are usually asymptomatic, and the diagnosis is made incidentally when rigid helices are noted on palpation and can be confirmed by radiological imaging. A biopsy can also help to differentiate between calcification and ossification. The presence of this condition may be a useful clinical sign, which in some cases precedes the development of endocrinopathies by many years. We report on a case, and we review the current literature. Petrified ears is an uncommon clinical entity: it describes auricular hardening, usually due to ectopic calcification or, less commonly, ossification of the cartilage. The diagnosis is made incidentally when rigid helices are noted on palpation and can be confirmed by radiological imaging. We report on a case showing a challenging surgical reconstruction after oncologic surgery, and we review the current literature.A 71-year-old man was referred for surgery for a squamous cell carcinoma of the left scapha A. He recPetrified ear is a rare diagnosis, which was first reported in 1866 by the Czech anatomist Vincent Bochdalek . The calReconstruction of the auricle after oncologic surgery is often complex due to the thin, adherent skin overlying a cartilaginous frame. In petrified ears, reconstructive surgery is particularly challenging because the calcified, stiff cartilaginous frame makes some reconstructive options  impractical. Even if two surgical steps were required, we considered that an interpolated transposition flap would be minimally at risk as to the vascular supply. The pre-auricular skin was chosen as the donor site because the mastoid region would have required either a trans-auricular tunnelization or, alternatively, an excessive bridging of the flap above the auricle. The final cosmetic result was excellent.Underlying systemic diseases, especially adrenal insufficiency, should be considered when patients present with petrified ear.


Postsurgical fat necrosis is a frequent finding in abdominal cross-sectional imaging. Epiploic appendagitis and omental infarction are a result of torsion or vascular occlusion. Surgery or pancreatitis are conditions that can have a traumatic and ischemic effect on fatty tissue. The imaging appearances may raise concerns for recurrent malignancy, but percutaneous biopsy and diagnostic follow-up assist in the accurate diagnosis of omental infarction. Herein we describe a case of encapsulated omental necrosis temporally related to gastric surgery. Preoperative CT and MRI findings showed the characteristics of encapsulated, postcontrast nonviable tumefaction in the epigastrium without clear imaging features of malignancy. Due to the size of the lesion and the patient’s primary disease, tumor recurrence could not be completely ruled out, and the patient underwent surgery. Histopathological analysis confirmed the diagnosis of steatonecrosis of the omentum. Intra-abdominal fat is metabolically active tissue that may undergo necrosis due to the torsion of an epiploic appendage, infarction of the greater omentum, and as a consequence of trauma or pancreatitis . EpiploiA 56-year-old male patient was admitted to our hospital with mild abdominal pain and palpable mass in the epigastric region. One year before, the patient underwent subtotal esophagectomy with transmediastinal gastroplasty and cervical esophago–gastro anastomosis due to squamous cell carcinoma of the proximal segment of the thoracic esophagus. Three cycles of chemotherapy were performed during which abdominal pain persisted. When the patient noted the palpable lump in the upper abdomen, he consulted a surgeon. Ultrasound examination of the abdomen showed a sharply delineated, incompressible, heteroechogenic tumefaction in the epigastric region. No inflammatory changes in the surrounding adipose tissue or the presence of free fluid were visualized. There were no signs of internal vascularization. Contrast-enhanced computed tomography (CT) was performed, and a hypodense, well-defined, clearly demarcated omental mass was revealed A,B.There was no significant postcontrast enhancement of the lesion, which showed discrete interspersed fat attenuation foci and several punctiform microcalcifications. There were no signs of the infiltrative character of the lesion or signs of angioinvasion or locoregional lymphadenopathy. Furthermore, an abdominal MRI exam showed a (T2-weighted) T2W heterointensive mass with irregular areas of higher signal intensity A. The leImaging features were predominantly benign, but due to the patient’s primary disease and lesion diameter, the malignancy could not be ruled out with certainty. The patient underwent open surgery, and the tumor-like mass was completely excided A,B.The histopathological finding correlated with encapsulated omental necrosis in the form of a secondary omental infarction that probably occurred as a consequence of an interruption to omental blood supply due to surgical manipulation at the time of gastric mobilization . The posThe greater omentum is a two-layered fold of the peritoneum arising from the greater curvature of the stomach without any attachment on three sides. It is highly mobile and susceptible to disruption of the omental blood supply, which can occur due to surgical manipulation during gastric or colonic mobilization, or by subsequent compromise during postoperative healing ,4.Fat necrosis occurs as a result of infarction of greater omentum, torsion of an epiploic appendage, or due to trauma or pancreatitis. Primary omental infarction can also occur in a hypercoagulable state, congestive heart failure, or thrombosis of the superior mesenteric vein or artery in obesity and professional marathon runners. It most often occurs in the right hemiabdomen due to the higher frequency of torsion of the right omentum .The most common symptom of omental infarction and acute appendagitis is abdominal pain that may be the cause of acute abdomen. The widespread use of CT scans in the evaluation of emergencies has increased the diagnostic confirmation of these conditions.Clinical presentation can also be completely asymptomatic, so these disorders are quite accidentally detected on surveillance imaging ,6.Accurate diagnosis is very important because most of these patients are treated conservatively. Secondary omental infarction is a consequence of surgery and can easily be misinterpreted in further follow-up as peritoneal dissemination of the disease or recurrence of malignancy .The ultrasound examination in primary omental infarction indicates a hyperechogenic mass with a very discrete hypoechogenic rim and edematous surrounding adipose tissue corresponding to inflammation. Reactive lymph nodes can often be observed. The mass shows no sign of internal vascularization or compressibility .CT presentation of primary omental infarction is an irregularly demarcated zone of soft-tissue stranding, predominantly fat density, and sometimes over 5 cm in size. Imaging appearance of the secondary omental infarction has been classified into four subtypes. Type 1 demonstrates an ill-defined fat attenuation lesion, type 2 shows a well-defined peripheral rim enhancement, while type 3 contains a partial fat component in a predominantly heterogeneous structure of the lesion, and type 4 represents a clearly delineated heterodense mass without a fat component .Encapsulated fat has a thin fibrous capsule and can be further complicated by inflammation and abscess formation. Calcifications are often detected intralesionally. It can easily be misdiagnosed with a malignant lesion because the capsule can show postcontrast viability on CT imaging. In such cases, CT shows an encapsulated mass, usually in the omentum. A fat component is not always observed. A discrete postcontrast capsule opacification can be observed as well as irregular internal septations . There iOn MRI, encapsulated fat necrosis is observed as a sharply demarcated lesion heterogeneous on T2-weighted images without complete fat suppression and mostly low IS on T1-weighted images. It can demonstrate high signal intensity on DWI and, therefore, resemble malignant lesions. It may present a variable degree of FDG uptake on PET/CT .One of the conditions in which adipose tissue necrosis can also be observed is pancreatitis, in which the process of fatty saponification may occur. Lipohypertrophy within the subcutaneous tissue has similar imaging characteristics and is found in patients who inject insulin injections ,12.To our knowledge, there are no cases of such extensive encapsulated omental necrosis described in the previous literature. The size of the lesion and its bizarre imaging features have raised suspicion of disease recurrence. Therefore, it is very important to keep in mind the complete clinical history of the patient as well as previous imaging studies in order to avoid further unnecessary examinations or even inappropriate treatments .The diagnostic features of encapsulated fat necrosis can be quite various and atypical. They can raise the suspicion of tumor recurrence or secondary dissemination of malignancy. Percutaneous biopsy, correlation of findings with previous imaging, and follow-up can help to avoid misinterpretation of such lesions and unnecessary procedures. In most cases, spontaneous resolution is expected unless it is complicated by inflammation that requires additional radiological and possibly surgical treatment.


A thymoma with chest pain and multilocular thymic cysts (MTCs) is very rare.A 49-year-old man presented to another hospital complaining of an anterior chest pain. Chest computed tomography (CT) showed an anterior mediastinal tumor 60 × 30 × 55 mm in size. The boundary with the pericardium or left brachiocephalic vein seemed to be partially unclear while enhanced by the contrast medium, and so the tumor could have invaded them. No definitive diagnosis of myasthenia gravis was made although the serum anti-acetylcholine receptor antibody count was high. We performed an extended thymectomy with combined partial resection of left brachiocephalic vein, left upper lobe, and left phrenic nerve. He was discharged with no chest pain and no complications post-surgery. The tumor was pathologically type B2 thymoma with hemorrhage necrosis and MTCs, and we diagnosed Masaoka stage II because of no histological infiltration to the organs.We speculated that hemorrhagic necrosis due to infarction in tumor caused the inflammation to spread to the surrounding organs, which was related to the chest pain and the development of MTCs. In general, a thymoma with chest pain is rare. The cause of chest pain has been reported to be associated with the necrosis in tumor –3, but tA 49-year-old man presented to another hospital complaining of an anterior chest pain. A chest computed tomography (CT) showed an anterior mediastinal mass that had cystic changes and the patient was referred to our hospital for examination and treatment. The physical examination showed no signs or symptoms of systemic or autoimmune disorder including myasthenia gravis (MG) such as muscle weakness. No definitive diagnosis of MG was made at our department of neurology. His laboratory test results revealed elevations in an anti-acetylcholine receptor antibody (AChR-ab) level (3.5 nmol/L). The contrast-enhanced CT on admission showed the size of tumor was 60 × 30 × 55 mm in diameter and the boundary with the pericardium or left brachiocephalic vein seemed to be partially unclear Fig. a. CT alsA surgical resection was conducted through a median sternotomy. The tumor was located on the left upper portion of the thymus. It showed a strong inflammatory adhesion of the surrounding tissues of the thymus, especially the left brachiocephalic vein, left upper lobe and left phrenic nerve though there was no invasion into the pericardium. We performed an extended thymectomy combined with partial resection of left brachiocephalic vein, left upper lobe and left phrenic nerve Fig. c. The toMicroscopically, the operative specimen showed that the tumor was 59 × 47 × 21 mm, and consisted of a solid lesion with a cystic component. Polygonal atypical cells with eosinophilic cytoplasm and round nuclei were proliferating in sheet form. In the upper part of the tumor, there was an extensive hemorrhagic necrosis suggesting infarction  [% 2, 3, , 3, 5–10The obvious cause of the necrosis within the thymoma is still unknown. However, Wright et al. reported that thrombotic changes in the vessels near the necrosis caused an infarction and resulted in hemorrhagic necrosis in the tumor . In our The cases of MTCs associated with thymoma is considered to be relatively rare, Nakamura et al. reported that the prevalence of thymoma with MTCs were approximately 17% . FurtherSymptoms of these thymomas were generally difficult to notice until they grew and progressed considerably. Although thymoma with chest pain adhered to surrounding organs due to the inflammation, it had a low invasion tendency and might have be detected early in a surgically resectable condition. Combined resection was required due to strong adhesion to the surrounding organs, but the postoperative pathological findings showed negative resection margins , 3, 5–10This report presented a surgically excised case of thymoma with MTCs discovered due to chest pain. Our case indicated that these symptoms may have been caused by hemorrhagic necrosis due to infarction in tumor. Chest pain caused by inflammatory spread may develop earlier than chest pain caused by tumor infiltration, and may lead to early detection in an operable condition.


Introduction. Gossypiboma is a rare surgical complication in small animals. The authors reported the laparoscopic diagnosis and treatment of an abdominal gossypiboma and chronic draining fistula postopen ovariohysterectomy (OVH) unresponsive to medical treatment in a bitch. Case Presentation. The patient had undergone OVH and exploratory laparotomy in other veterinary practice 3 years previously. The animal, presenting a chronic fistula, was then referred to UFSM Veterinary Hospital. Ultrasonographic examination revealed a structure compatible with a granuloma. For the laparoscopic procedure, a 3-port  access was used. Adhesiolysis and mass removal were performed by blunt dissection and bipolar electrocoagulation. The fistula was treated by mobilising the omentum through it. There were no intra- or postoperative complications. The chronic wound showed first intention healing. The mass was composed of fibrous tissues surrounding one surgical gauze. Discussion and Conclusion. The removal of a retained surgical gauze in the abdomen by laparoscopy has already been described in medicine. However, a laparoscopic approach for treating a fistulous draining tract due to a gossypiboma has not been previously reported in dogs. Laparoscopic exploration of the fistula allowed the use of a pedicled omental flap through infected sites to control chronic infection. Laparoscopic surgery can be used to identify and treat abdominal gossypiboma in dogs, including those with chronic abdominal sinus. The maintenance of gauze compresses inside the patient, also known as gossypiboma, textiloma, cottonoid, or muslinoma , 2, is aTo the best of the authors' knowledge, this is the first case report of the use of laparoscopic procedure for the diagnosis and treatment, during the same surgical act, of a dog presenting a severe and chronically infected abdominal fistula due to gossypiboma. This study was reported according to the SCARE criteria .A five-year-old female mongrel dog (10.8 kg) was referred from another Brazilian state to the Veterinary Hospital at the Federal University of Santa Maria (UFSM) for exploratory laparoscopy under diagnosis of an intra-abdominal mass with chronic fistulous draining tract that was unresponsive to a previous treatment.The animal had undergone elective ovariohysterectomy at another veterinary hospital 3 years earlier. A few months later, the dog presented with a chron.ic draining fistula that was not responsive to clinical treatment with different classes of antibiotics, including cephalosporin, amoxicillin, clavulanic acid, and enrofloxacin. An exploratory laparotomy at another veterinary hospital revealed a mass next to the caudal pole of the right kidney, which was not removed or referred to biopsy for unknown reasons. Material was collected from the sinus for antibiogram analysis, showing sensitivity to amoxicillin-potassium clavulanate and cephalexin, among others, with the latter being the antibiotic prescribed and administered for approximately the next 4 months. However, the drainage did not cease. The animal was then referred to the UFSM for laparoscopic diagnosis and possible treatment.μL), and mild leukopenia (5 μL) due to lymphopenia (900 μL) were observed in the total blood count. Serum biochemistry also revealed an increase in gamma-glutamyl transferase (21.64 UI/L). Then, the dog was referred to a minimally invasive surgery service of the hospital  on the same day to investigate the intra-abdominal mass and the cause of the chronic infection. A prior computed tomography scan was not undertaken because it was unavailable and close to the region (in a radius of more than 300 km).In the clinical examination at the UFSM, the animal presented with a chronic fistula draining a purulent content located at the right flank close to the iliac crest. A drain, inadequate in size and type, was found inserted through the fistula. Ultrasonographic examination revealed a circumscribed structure caudal to the right kidney with acoustic shadowing resembling a granuloma. Elevation of plasma protein values (9.2 g/dL), thrombocytopenia , midazolam (0.4 mg/kg), and morphine (0.4 mg/kg), adequate hygiene and hair clipping of the flank were provided. Anaesthesia was induced with propofol and maintained with isoflurane in 100% oxygen. The dog was positioned in dorsal recumbency for laparoscopic surgery. The sinuous path was irrigated after drain removal. Then, a 3-port laparoscopic approach was selected. After skin antisepsis, an 11 mm port was placed on the preumbilical midline using the open technique (Hasson-modified) . The CO2gulation .The first intra-abdominal inspection revealed a mass at the right kidney pole, at the right ovary site, as well as intraperitoneal adhesions . The masThe tip of a 5 mm cannula attached to a vacuum cleaner was inserted through the fistula, which was thoroughly rinsed with 0.1% povidone-iodine solution . A cutanNo intra- or postoperative complications were observed. The total surgical time, from first incision to skin closure, was approximately 200 min. The animal recovered uneventfully in the early postoperative period and was discharged the same day with cephalexin, tramadol, and meloxicam . All wounds had first intention healing, and all sutures were removed 8 days after surgery.Postsurgical immediate macroscopic observation of the specimen revealed a surgical gauze involving a thick fibrous capsule Figures . HistoloThe patient recovered completely, and the animal did not present any complications for 5 years. In contact via telephone, the owner reported that the animal was diagnosed with a cutaneous hemangiosarcoma and died due to complications related to its management at another veterinary facility.The present report highlights the use of laparoscopy to assess and treat a complicated case of gossypiboma with a fistulous draining tract in a dog. This approach has not been previously reported in the literature. Moreover, this case report describes the innovative use of a laparoscopic-assisted omental flap through the fistula to treat a chronically infected wound.A. jubatus) [The use of laparoscopy in the removal of abdominal retained surgical gauze has been described in humans , 6 and ijubatus) . Similarjubatus)  reportedWe chose to insert the first portal in the midline to evaluate the abdominal cavity as far as possible and to choose the best location for the other two portals. After assessing the cavity, the second and third portals were placed on the right flank, in a position similar to that used for laparoscopic nephrectomy . AdhesioIn the current report, it was not possible to establish a safe dissection plane at the site of the gossypiboma attachment to the inner abdominal wall, close to the fistulous tract. Therefore, laparoscopic hydrodynamic debridement was selected to explore the fistula and rinse the saline solution from the abdominal fistula site to the cutaneous ostium. This provided fluid drainage from the inside, avoiding intraperitoneal contamination. Subsequently, the sinus tract and the defect were covered with an omentum flap, which was based on previous successful outcomes using a pedicled omental flap through infected sites .According to a previous study, the use of an omental flap can control chronic infections . OmentumWashing wounds and cavities using 0.1% povidone-iodine is unusual in small animals. However, this is a practice described in paediatric surgery in medicine , which wConsidering the severity and chronicity of the fistula, laparoscopic-assisted thorough irrigation and omentalisation was feasible and provided optimal management of the draining tract. Moreover, the authors suggest that such a minimally invasive approach should be attempted before performing exploratory celiotomy to manage intraperitoneal fistulas in dogs.The laparoscopic approach provides accurate identification and treatment of abdominal gossypiboma in dogs, including complex cases of complicated chronic abdominal fistulas.


Urachus adenocarcinoma is an extremely rare malignant tumor characterized by its insidious evolution responsible for the delay in diagnosis. Several scientific works have tried to study the indication of adjuvant treatment, therefore the prognosis is still poor.We report the case of a 50-year-old patient with no pathological history who consulted for an episode of intermittent urinary mucosal secretion aggravated by the appearance of macroscopic hematuria. Without other associated clinical signs. Imaging examinations revealed a mass at the expense of the upper wall of the bladder. The cystoscopy allowed us to visualize the mass and the biopsy. Histological study revealed an adenocarcinoma of urachus. The patient underwent surgical exeresis and adjuvant chemotherapy. The evolution was marked by a deterioration of the general condition despite adequate management.Due to its topography, urachus cancer usually manifests as a bladder tumor, exceptionally as much as an anterior umbilical or extraperitoneal tumor. Few studies have been done on this neoplasm; however surgery still has a primary place in therapeutic management.The scarcity of cases of urachus cancer makes the publications scarce and the lack of multicenter clinical and randomized trials explains the disagreement about adjuvant treatments. •Urachus cancer is a rare malignant tumor.•The tomodensitometry is the reference examination which makes it possible to think of the diagnosis in front of a mass of urachus.•Surgery remains the gold standard for therapeutic management.•The prognosis is pejorative because of the aggressiveness of the tumor of the delayed diagnosis. It accounts for 0.17% of bladder tumors and 0.01% of adult cancers [The clinical presentation remains insidious and variable ranging from a simple mucous urinary secretion to a giant abdominal mass. As a result of this silent clinical course, uracal adenocarcinoma still has a poor prognosis.Imaging has an essential place in the diagnosis, the therapeutic strategy and the evolutionary follow-up. Surgery remains the benchmark for therapeutic care. Radiochemotherapy is still awaiting a randomized multicenter scientific evaluation and the advent of new, more effective molecules. Tumor markers such as CA125 play an important role in postoperative surveillance. The objective of our clinical case is to highlight one of the rare aspects of revelation of malignant uraque tumors and to discuss the possible methods of diagnosis and management. This work has been reported according to SCARE 2020 criteria [2A 50-year-old patient, mother of 3 children with no pathological history. She consulted for an episode of intermittent urinary mucosal secretion for 5 months worsened by the onset of macroscopic hematuria progressing for 1 month. Without other associated signs, all taking place in a context of conservation of the general condition. The abdominal examination, pelvic examinations as well as the somatic examination are unremarkable.The bladder ultrasound revealed an echogenic tissue process of the anterior bladder wall measuring 50 × 25mm .Fig. 1UlCystoscopy performed under spine anesthesia uncovered a large bladder tumor at the expense of the anterior wall, sessile macroscopic appearance, fleshy and with a broad implantation base, suggesting an infiltrating tumor. The rest of the bladder lining was unremarkable.The anatomopathological study after endoscopic bladder resection revealed a colloid mucous carcinomatous tumor proliferation. It shows, within large areas of mucus, the presence of isolated carcinomatous cells in the form of a signet ring or the form of small clumps. These extend over the entire mucosa with extension to the muscle layer. The pathologist concluded that there was a colloid mucous adenocarcinoma.Laboratory workup revealed a hemoglobin level of 13.6 g/dl. Renal function is normal with blood urea at 0.25 g/l and serum creatinine at 7 mg/l. The tumor markers showed no abnormalities, the CA 125 at 19.2 U/ml and the ACE at 19.96 ng/ml.Computed tomography shows a bladder tumor process budding at the expense of the anterior and left lateral wall with exophytic development and site of calcifications. It measures approximately 72 × 48.6 × 73.2mm. It is also associated with an infiltration of neighboring fat. Also, the liver is of normal size. At the level of its segment, VI sits a hypodense nodular lesion measuring 14.5 × 14mm, discreetly enhancing after injection of PDC ; 3 and 4The patient underwent a rectosigmoidoscopy to look for a neighboring tumor that was without abnormality. After multidisciplinary consultation, it was decided to start with surgical treatment, then to refer the patient to the oncology department for adjuvant chemotherapy. The patient was operated on in our urology department.Two weeks after confirmation of the diagnosis, the operative procedure was performed under general anesthesia after draping and bladder catheterization. It consisted of performing an anterior pelvectomy removing the bladder with urachus as well as the uterus, appendages and anterior wall of the vagina. The urinary diversion was a bilateral ureterostomy. Postoperative clinical and laboratory monitoring was without abnormalities.The anatomopathological examination of the surgical specimen shows a resection specimen carrying the bladder and the uterus in one piece with the appendages in place, the right ureter is resected over 2cm, the left over 1.5cm; the outer surface of the bladder is multi-nodular in appearance. Microscopic examination noted the presence of a submucosal neoplasm at the level of the bladder dome and on the anterior surface, ulcerating in places the bladder mucosa and budding endoluminal. The neoplasm is shiny whitish in appearance, the site of extensive calcium changes. It largely infiltrates the muscular and serosa bladder remaining 1mm from the excisional surface and respecting the uterine wall. The right and left lymph node dissection each weighs 10g.Histological examination shows that the neoplasm corresponds to a carcinomatous proliferation infiltrating the bladder wall from the outside to the inside with a maximum tumor volume located in the serosa and muscularis.The proliferation is arranged in large pools of mucus cut into lobules by fibrous septa. Within these pools are found carcinomatous structures arranged in clusters and tubes or isolated cells taking a Signet ring appearance. The cells have abundant mucosecreting cytoplasm and atypical nuclei with abnormal mitoses. It is noted vascular emboli and peri-nervous sheaths. The proliferation comes into contact with the exeresis surface of the bladder serosa.The bladder mucosa is free from carcinoma in situ lesions and foci of glandular metaplasia. The urethral and ureteral extremities are free.The right ovary is infiltrated by the carcinomatous proliferation described above and the right tube, as well as the left appendix, do not present any particularities.The pathologist concluded that there was a bladder localization of a mucous colloid adenocarcinoma with a signet ring cell component. Presence of vascular emboli and perinervous sheath. The margins of exeresis of the bladder serosa were tumor with right ovarian metastasis and absence of lymph node metastasis.The immunohistochemical study shows a carcinomatous proliferation diffusely expressing CK7, ACE, and focal CK20, CDX2. The patient was subsequently referred to the oncology department where she received adjuvant chemotherapy such as Folfox based on oxaliplatin, folic acid, and 5-fluorouracil.She received 10 cures and presented side effects consisting of intense fatigue, nausea, vomiting, and transit disorders, all supported by symptomatic treatment. Control CT scan 1 month after surgery: shows pelvic fat infiltration without detectable mass, with persistence of hepatic lesion of segment VI .Fig. 5ThThe evaluation computed tomography one year after treatment: shows an aspect of peritoneal carcinoma made up of a significant nodular infiltration of the pelvic fat, site of calcifications, supra, and retrohepatic.Lung lesions formed by two nodules, right apical and middle lobar with non-septal postero-basal thickenings. Well, limited hepatic hypodense lesion of segment VI measuring 11 × 10mm. Mixed bone lesions, with periosteal reaction to grass fire of the left acetabulum and the right ischiopubic branch , Fig. 7.A computed tomography scan two years after treatment revealed the presence of three dense parenchymal pulmonary nodules with upper right lobed polylobed contours. The dysmorphic liver has several hypodense nodules, two in segment VI, one in segment II and four in segment IV. Lumpy infiltration of peritoneal fat with an effusion of moderate abundance. Mixed bone lesions with periosteal reaction to grass fire involving the two ischio-pubic branches and the left acetabulum with infiltration of the adjacent soft parts.Over two years, the patient underwent regular clinical and paraclinical evaluation. Clinically, the patient weakened and became bedridden and cachectic (PS: 3), despite adequate vitamin-protein supplementation. Radiologically, the evolution was marked by an aggravation of the pre-existing lesions as well as the appearance of new pulmonary, hepatic, peritoneal, and bone lesions. The patient died two years after the start of treatment.3The first citation of the urachal tumor in the literature was reported by the scientific work of Hue and Jacquin in 1863 ,5. HowevFrom an embryological point of view, the uraque and the dome of the bladder have the same endodermal origin while the rest of the bladder has a mesodermal origin. This origin has an impact on the choice and the therapeutic strategy . The uraDue to its topography, urachus cancer usually manifests as a bladder tumor, exceptionally as much as an anterior umbilical or extraperitoneal tumor .Hematuria is a vital sign of urachal cancer. It is often associated with other functional or physical signs that are rarely isolated. Its abundance is variable , it is generally terminal or total with terminal reinforcement .Irritative signs are present in 50% of cases, attesting to compression or infiltration of the bladder wall of the urachus. Hypogastric pain is found in 20% of patients, which proves the non-specificity of this sign. The presence of an abdominal mass is encountered in 9–32% of cases, urinary mucous secretions, umbilical fistula, and distant metastases are rare but can also be revealing .Punctiform hypogastric calcifications can be objectified by an abdominal x-ray without preparation. Intravenous urography (IVU) shows subtraction images at the level of the bladder dome at a late stage of development. IVU, retrograde cystography, and fistulography are no longer of interest after the advent of CT scans .Abdominopelvic ultrasound may show bladder invasion and metastatic secondary locations. In 90% of cases, a cystoscopy coupled with an abdominal palpation can reveal a tumor of the anterior surface or the dome and make possible a transurethral biopsy .Computed tomography is the gold standard, in specific ways the tumor is divided into an intravesical caudal part and a cystic, solid, or supra-bladder solidocystic part. The presence of calcifications which are often peripheral can also be central. It also determines the degree of bladder, lymph node, or metastatic invasion. It also guides the performance of scano-guided biopsies and the monitoring of local or remote recurrences after surgery . MagnetiThe gold standard for surgery has long relied on omphalectomy, extensive resection of the urachus, anterior parietal peritoneum, posterior rectus fascia, as well as cystectomy and prostatectomy in men. In practice, performing a total cystectomy remains controversial because of the possibility of a 2cm excision margin at the level of the bladder section. An extemporaneous examination will be of great importance intraoperatively. However, partial cystectomy and omphalectomy are correlated with a five-year survival of the same order as that obtained after radical surgery with a higher local recurrence rate ,17.Uraque cancers are not very radiosensitive, nevertheless an adjuvant postoperative irradiation of the tumor bed or in inoperable cases, as well as to treat local pain and direct tumor compressions or by metastases.According to several studies, the benefit of chemotherapy remains ineffective. One job that compared the cisplatin and 5FU-based protocol with abstention found a similarity in overall survival. An elevated level of CA125 is a useful marker for postoperative follow-up which may warrant additional chemotherapy .4The scarcity of cases of urachus cancer makes the publications scarce. The absence of a specific clinical sign leads to a delay in diagnosis, which is responsible for the poor prognosis of urachal adenocarcinoma. Ultrasound can detect this tumor at an earlier stage. TMD and MRI have a central place in diagnosis, treatment, and monitoring. The therapeutic strategy consists of a partial or total resection of the bladder including the urachus and the umbilicus. The lack of multicenter clinical and randomized trials explains the disagreement about adjuvant treatments.The study committee of the jura sud hospital center approves the favorable opinion to publish this work.We have any financial sources for our research.Dr. EJ, Dr. IJ, and Dr. CB analysed and performed the literature research, Pr. HL performed the examination and performed the scientific validation of the manuscript. Issam Jandou was the major contributors to the writing of the manuscript. All authors read and approved the manuscript.Name of the registry:Unique Identifying number or registration ID:Hyperlink to your specific registration (must be publicly accessible and will be checked):Dr. Jandou issam.The consent to publish this information was obtained from study participants. We confirm that written proof of consent to publish study participants are available when requested and at any time.All authors disclose any conflicts of interest.


Mitral annular calcification (MAC) is a common pathology of the mitral valve. In rare cases, calcifications occur in the mitral annulus degenerate serous; the caseous calcification of the mitral annulus (CCMA) then develops. Detection of CCMA is often random and requires differentiation from heart tumors or an abscess. The paper presents two cases of patients with ambiguous focal lesions of the mitral valve in echocardiography. In the first case, the cardiac computed tomography (CCT) showed a spherical, slightly irregular structure measuring approximately 33 × 22 mm, which was in contact with the posterior mitral valve leaflet from the lumen of the left ventricle. The lesion was heterogeneously intense, with an average density of about 500 HU and up to 975 HU on the periphery; it was not enhanced after the administration of a contrast agent. In the second case, the CCT revealed a heterogeneous, highly calcified structure in the peripheral zone and intermediate density in the central zone in the topography of the posterior mitral valve leaf, with dimensions up to about 41 × 31 mm in the plane of the valve leaflet, passing into the lumen of the left ventricle along its inferolateral wall to a depth of about 3.5 cm. In both cases, CCT enabled the diagnosis of CCMA. In conclusion, cardiac computed tomography may be decisive in the case of suspected caseous calcification of the mitral annulus where there is ambiguous echocardiography. Mitral annular calcification (MAC) is a common degenerative condition of the mitral valve. MAC affects approximately 8.5% of the general population ,2. CalciCaseous calcification of the mitral annulus usually presents as a round or crescent-shaped soft mass with central clearances, which is often seen in transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) and is very well visible in cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR). Most of the described cases concern the posterior part of the mitral ring, while lesions in the anterior or the entire ring are less frequently reported ,3.CCMA is usually asymptomatic or mild, and its detection is often incidental and misdiagnosed as a heart tumor or abscess. Sometimes, however, it causes symptoms such as conduction abnormalities or causes systemic embolization with caseous material.This report presents two cases of caseous calcification of the mitral annulus, aiming to emphasize the diagnostic importance of cardiac computed tomography in the assessment of heart valve morphology and the differentiation of tumor-like lesions of the heart.This was a 76-year-old patient with diagnosed arterial hypertension, treated for glaucoma after a total thyroid resection due to malignant glaucoma. They were admitted to the Department of Cardiology, in good general condition, due to suspected myxoma or other neoplastic lesions in the mitral valve after TTE in an outpatient setting. Reported complaints included weakness and decreased capacity for physical activity.After the patient was admitted to the Department of Cardiology, the TTE was performed again, showing a spherical, intensely saturated structure with a diameter of about 2 cm in the posterior pole of the mitral ring, with slight lightening in the central part. The formation seemed to be stably attached to the annulus and posterior leaflet of the mitral valve on the left atrium side. It was suggested that MAC was a possibility, and the diagnosis was extended to include TEE. In addition to the lesions described above, the study revealed mild aortic regurgitation, moderate tricuspid regurgitation, and regional contractility abnormalities in the lesion found.Through TEE, the presence of myxoma was excluded, and there was a trace of mobility of the posterior mitral valve leaflet supported by calcification from the left ventricle. The nature of the lesion was not resolved, which was associated with the decision to refer the patient for a CCT.The CCT showed a spherical, slightly irregular structure measuring approximately 33 × 22 mm, which was in contact with the posterior mitral valve leaflet from the lumen of the left ventricle. The lesion was heterogeneously intense, with an average density of about 500 HU and up to 975 HU on the periphery; it was not enhanced after the administration of a contrast agent. The images in the CCT allowed for the diagnosis of CCMA, The patient remains under observation. There was no progression in the echocardiographic assessment in the 1-year perspective.This patient was a 78-year-old woman presenting with atrial fibrillation and symptoms of CCS (Canadian Cardiovascular Society) class III angina during the routine check on the condition of a 2-lead pacemaker showing a low battery level. To replace the pacemaker, the patient was admitted for a one-day procedure to the Department of Cardiology, where a TTE was routinely performed. Through TTE, in addition to the features of moderate mitral and tricuspid valve regurgitation, significant thickening of the mitral ring and a mass of 2.9 × 1.8 cm in the lower pole projection, which included the basal inferior and anterolateral walls of the heart and convexed to the side of the heart, was visible.After replacing the pacemaker battery, the symptoms of angina pectoris were partially resolved to class II on the CCS scale.To further diagnose the suspicious lesion, a TEE and a CCT were performed as part of the one-day admission procedure.In the TEE, in addition to the features of moderate mitral and tricuspid valve regurgitation, massive calcifications in the mitral ring forming a conglomerate approximately 2.0 × 1.1 cm from the pole side of the lower ring were discernible—an image suggestive of MAC. The CCT revealed a heterogeneous, highly calcified structure in the peripheral zone and intermediate density in the central zone in the topography of the posterior mitral valve leaf, with dimensions up to about 41 × 31 mm in the plane of the valve leaflet, passing into the lumen of the left ventricle along its inferolateral wall to the depth of about 3.5 cm—the CCT image indicates CCMA, This patient is also under observation. In the control TTE after 8 months, there was no significant change in the size of the lesion.Based on the studies conducted so far, the incidence of CCMA is considered low, ranging from 0.06% to 0.07% in the entire population, and up to 0.6% of patients with MAC. On the other hand, the frequency of occurrence in autopsies is higher and amounts to approximately 8% of the studied population. This condition is therefore probably being underdiagnosed due to its asymptomatic course in most patients [Previous reports have shown that TTE was considered the most reliable method of diagnosing this disease. Caseous degeneration of the mitral flap manifests itself as a large, round mass with a dense echo and smooth borders in the pericardial region. Additionally, it should not have an acoustic shading effect. It was reported to be usually posterior to the left ventricle and bulging into the left atrium or the posterior wall of the left ventricle. With limited acoustic visibility or low-quality echocardiographic images, patients were referred for TEE, which has so far provided good visualization of the posterior structures. In both examinations, CCMA does not flow in the central zone in color Doppler and is surrounded by a hyperechoic structure . When inThe presented cases indicate CCT as a diagnostic method enabling early and precise diagnosis of CCMA. They provide data for the ongoing discussion on the diagnostic accuracy of various imaging methods. Additionally, other advantages of using CCT as a CCMA imaging method should be highlighted. They include much better spatial resolution independent of the acoustic window and better tissue resolution compared to TTE, the non-invasive feature of the diagnostic procedure compared to TEE, significantly shorter examination time, better availability, and lower economic cost compared to CMR. The presented images were obtained using one of the most advanced computed tomography scanners currently available—384 2 × 192) slices Siemens Somatom Force . Such a computed tomography scanner enables the acquisition of images in layers of 0.6 mm thickness, with a time resolution of <0.3 s, with a low dose of ionizing radiation <1 mSv and a low volume of contrast agent <60 mL 2 slices ,11.In the natural history of all types of MAC, a slow progression in the severity of the lesions is observed . In the Calcification of the mitral annulus has been associated with the risk of stroke , infective endocarditis, and atrial fibrillation. Increasing the thickness of the lesions by 1 mm resulted in a 10% increase in the risk of stroke ,13. In aThere is no standard CCMA treatment protocol. Surgery is indicated in the event of severe mitral valve dysfunction (related primarily to other diseases). Surgical management has been implemented with great success in cases of CCMA with severe symptomatic mitral regurgitation, stenosis, or systemic embolization of the caseous material . CCMA isThe limitation of the present case presentation is the lack of images from other diagnostic methods. Unfortunately, no images were recorded during the TTE and TEE examinations. Due to the final diagnosis in the CCT method, no further diagnostic procedures  were performed.Cardiac computed tomography may be decisive in the case of suspected caseous calcification of the mitral annulus where there is ambiguous echocardiography.


Müllerianosis of the urinary bladder is an extremely rare, benign condition defined by the presence of at least two of the three müllerian-derived components  in the lamina propria and muscularis propria of the urinary bladder. It frequently mimics neoplastic condition, either malignant or benign. Here, we present a case of cystic müllerianosis of urinary bladder, which was clinically thought to be a urinary bladder neoplasm. Müllerianosis of the urinary bladder is a benign condition characterized histopathologically by the presence of at least two of the three müllerian-derived components  in the lamina propria and muscularis propria of the urinary bladder . It is aA 31-year-old nulliparous woman presented with the complaints of menorrhagia and pelvic pain for seven months. She also complained of pain during micturition and increased urinary frequency during her menstrual cycles for the same duration. Contrast-enhanced CT scan of the abdomen and pelvis showed multiple uterine fibroids with both subserosal and submucosal components. To relieve her bulk symptoms, she underwent laparoscopic total hysterectomy with bilateral salpingectomy. During the laparoscopic surgery, a 2-3 cm nodule was visualized above the urinary bladder trigone. The nodule was hard and did not extend through the bladder serosa. Of note, the CT scan prior to the surgery did not show this lesion.For further evaluation, the patient underwent an elective cystoscopy which revealed a nodular lesion with calcification on the posterior wall of the urinary bladder, which was highly suspicious for a neoplasm. The patient underwent a transurethral resection of this urinary bladder nodule. Histopathological examination showed a cyst within the urinary bladder wall, lined by tubal-type epithelium and endometrial-like pericystic stroma Figure . CD10 stMüllerianosis of the urinary tract is an extremely rare condition with less than 40 cases reported to date -14. It iSymptoms include abnormal uterine bleeding, hematuria, dysuria, pelvic pain, and suprapubic pain, which may or may not be associated with menstruation. Patients with ureteric lesions often had symptoms suggestive of ureteric obstruction or hematuria. The symptoms of our patient were associated with menstruation.Both implantative and metaplastic origins have been suggested as pathogenesis of these lesions ,18. In nUltrasound, MRI, or urinary cytology showing epithelial aggregates with papillary configurations have been useful for the diagnosis. Radiologically, müllerianosis can be seen as a polypoid mass on ultrasound, CT scan, or MRI. A preferred diagnostic imaging modality has not been identified because of such a small number of patients that have been reported with this condition. Interestingly, CT scan of the abdomen and pelvis did not reveal any urinary bladder nodule in our patient, and it was only seen on cystoscopy. There have been two cases reported in which the diagnosis was suggested by urine cytopathology which showed endometrium-like cells .Differential diagnosis of müllerianosis of the bladder includes cystitis glandularis, cystitis cystica, bladder adenocarcinoma, carcinoma of the urachus, and neoplastic lesions, including cervical cancer invading into the bladder wall. Definitive diagnosis is by histopathologic evaluation after cystoscopic removal of the lesion.Treatment of müllerianosis is controversial, and modalities include pharmacotherapy with gonadotropin-releasing hormone (GnRH) agonist or with surgical resection of the lesion. Two cases have been reported where treatment with GnRH resulted in resolution of symptoms; however, the size of the lesion continued to persist ,11. BecaDespite the benign nature of bladder müllerianosis, some reports have described malignant transformation of the müllerianosis into bladder endometroid carcinoma . Due to In summary, müllerianosis of the urinary bladder closely mimics a urinary bladder neoplastic lesion in terms of clinical presentation, cytology, and cystoscopic findings ,19. AccuMüllerianosis is a rare condition that can be considered to be a pseudoneoplastic bladder lesion potentially responsible for a false diagnosis of malignancy. Due to its rarity, definitive guidelines for management are lacking. Recommended imaging modality, probability of malignant transformation, and time interval for surveillance are few of the many areas that need further exploration. We report this case to add to the general knowledge about müllerianosis.


Objective: To describe an interesting case of miliary tuberculosis mimicking retinoblastoma.Method: A retrospective case report.Result: The twin brother of a known case of retinobastoma presented with headache. On fundus examination, multiple yellowish-white lesions were noted in both eyes. Magnetic resonance imaging of the brain showed multiple enhancing lesions. A diagnosis of miliary tuberculosis was made and anti-tubercular therapy was started.Conclusion: Ocular tuberculosis can mimic retinoblastoma and lead to diagnostic dilemma especially in cases with family history of retinoblastoma. Retinoblastoma is the most common childhood intraocular malignancy. Several pediatric ocular conditions can have similar presentation. The common causes of pseudoretinoblastoma include Coats disease, persistent fetal vasculature, familial exudative vitreoretinopathy, vitreous hemorrhage, toxocariasis, retinal detachment, coloboma, astrocytic hamartoma and endogenous endophthalmitis , 2]. Th. Th2]. TThe dizygotic twin brother of a known case of bilateral retinoblastoma, born following in-vitro fertilization was being screened annually for retinoblastoma. There was no other family history of retinoblastoma. No pathology was noted in the first two years of screening. At 3 years of age, he presented with headache. Vision was 20/20 in both eyes. Examination under anaesthesia revealed multiple yellowish-white retino-choroidal lesions. A solitary lesion of size 0.5 mm in the right eye superior to the disc and two similar lesions in the left eye, one superior to fovea and the other inferior to the disc (Figure 1A, B Choroidal tuberculoma can mimic retinoblastoma, especially in children with a strong family history of retinoblastoma. Among the various mimickers of retinoblastoma, choroidal tubercle is a rare differential diagnosis. Few cases of ocular tuberculosis have been misdiagnosed as retinoblastoma and have undergone enucleation, only to be diagnosed as tuberculosis later on histopathology , 4], , .In a child with systemic tuberculosis presenting with retinochoroidal lesions, ocular tuberculosis should be strongly suspected. Rarely choroidal tubercles can mimic retinoblastoma and lead to diagnostic dilemma especially in children with family history of retinoblastoma.The authors declare that they have no competing interests.


Congenital hypertrophy of the retinal pigment epithelium is a rare benign tumor of the ocular fundus that may vary according to three types. It is frequently asymptomatic and diagnosed during routine ophthalmology exam. This lesion has an important differential diagnosis with retinal disease and may be related to systemic diseases, therefore, it is essential to recognize it and keep the follow-up. In this paper, three different cases of each type of CHRPE were described and documented. Abbreviations: CHRPE = Congenital hypertrophy of the Retinal Pigment Epithelium, RPE = Retinal Pigment Epithelium, CDVA = Corrected Distance Visual Acuity, PIO = Intraocular Pressure, FA = Fluorescein Angiography, FAP = Familial Adenomatous Polyposis, RPEH-FAP = Retinal Pigment Epithelial Hamartomas Associated with Familial Adenomatous Polyposis, OCT = Ocular Coherence Tomography It occurs due to a proliferation of larger and more numerous cells of the RPE containing larger melanosomes - a combination of cellular hyperplasia and hypertrophy. It is a lesion with well-defined margins, flat or minimally elevated, round, soul lesion, with dark color and cut edges. The lesions may be depigmented in senior patients . CHRPE represents a group of disorders that can have three varieties: unifocal CHRPE, multifocal CHRPE (“bear tracks”) or atypical multifocal CHRPE .The CHRPE is a benign uncommon finding that occurs due to a proliferation of the cells of the pigmented epithelium. It is frequently a flat or minimally elevated pigmented, round, oval lesion, with well-delimited margins that emerge from the periphery of the ocular fundus. A depigmented halo located inside the lesion may commonly appear . The atypical multiple entity is bilateral, has multiple oval, fishtail or comma-shaped lesions, associated with margins and perilesional area, which is irregularly hypopigmented [5].The typical isolated CHRPE represents a flat or minimally elevated pigmented, round or oval, well-delimited lesion that typically appears from the peripheral fundus. The multiple congenital hypertrophies of the RPE  was created [5].The last type of CHRPE presents a close relation to Familial Adenomatous Polyposis (FAP) and others syndromes such as Gardner and Turcot. Due to this condition, the thorough investigation of the family history, neuroepithelial tumors of the central nervous system and a colon propaedeutic are necessary. To distinguish the entities that are not associated with gastrointestinal malignancy, the term “6,7]. Gardner syndrome is an autosomal dominant condition that starts in advanced ages with colorectal polyps, osteomas of mandible and long bones, epidermoid cysts, and other features .FAP is an autosomal dominant disease with elevated penetrance characterized by the emergency of hundreds to thousands adenomatous polyps frequently during the second decade of life. Its evolution to colorectal carcinoma is considered inevitable in patients not undergoing prophylactic colectomy .Differential diagnosis can be presented by inflammatory, infectious, reactive, or neoplastic chorioretinal lesions, as melanocytic choroidal naevus, melanomas, choroidal melanocytoma, subretinal hematoma, epiretinal membrane, hyperplasia of the retinal pigment epithelium (RPE), adenoma or adenocarcinoma of the RPE, retinal and choroidal hamartoma [1]. The ultrasound frequently evidences that the RPE hypertrophy is flat or minimally elevated and slightly hyperreflexive . The FA shows hypofluorescence, except for the atrophy areas, which are hyperfluorescent [1-3]. The lesions are hypoautofluorescencent in the autoFA [3]. In the ocular coherence tomography (OCT), the overlying retina is thinned and the retinal pigment epithelium can be thickened or thinned. The choroid has normal thickness and vascular appearance underlying the CHRPE compared to the immediate tissue outside the lesion margin [8].The ultrasound and fluorescein angiography (FA) are typically used to distinguish the hypertrophy of the RPE from the uveal melanoma and rare intraocular tumors [6]. Any treatment is necessary, but the follow-up is essential because if there is an increase in size or an appearance of a protruding nodule, it can be an adenoma or adenocarcinoma, and a few cases can develop a choroidal neovascular membrane above the lesions . In addition, the investigation of FAP is essential in patients with ocular findings, especially in the atypical variety.The CHRPE are benign lesions that are generally diagnosed accidently during an ophthalmology routine exam, being necessary to know how to distinguish them from the threatening injuries [The CHRPE is a benign rare finding diagnosed occasionally during a routine exam that needs to be known by the ophthalmologists. In the most cases, any treatment is necessary, however, is important to distinguish it from other pigmented suspect lesions. Conflict of interestThe authors declare no conflicts of interest.Informed Consent and Human and Animal Rights statementsInformed consent has been obtained from all individuals included in this study.Authorization for the use of human subjectsEthical approval: The research related to human use complies with all the relevant national regulations, institutional policies, is in accordance with the tenets of the Helsinki Declaration, and has been approved by the Ethics Committee of Faculda de Ciências Médicas, Belo Horizonte/MG, Brazil.AcknowledgementsNone.Sources of fundingAll authors had no financial disclosures or support in this work. The authors declare that their research has not been funded by any entity.DisclosuresNone.


Gastric diverticula are the least common gastrointestinal diverticula. Patients can be diagnosed incidentally on EGD or present with variable symptoms such as abdominal fullness, anorexia, and perforation. Gastric diverticula can be acquired from malignancy, peptic ulcer disease, or prior surgery or be congenital. Treatment varies based on symptomatology ranging from conservative medical management with proton pump inhibitors to surgical treatment with open or laparoscopic resection. We present a case of a 73-year-old female with acquired gastric diverticulum presenting as a gastric outlet obstruction who was successfully treated with conservative medical therapy. H. pylori infection and esophagogastroduodenoscopy (EGD) at that time.A 73-year-old female with a history of peptic ulcer disease (PUD) presented with intractable nausea, vomiting, and epigastric pain. Her PUD was initially diagnosed in the 1980's as an ulcer initiated by an upper gastrointestinal (GI) series and successfully treated with omeprazole. There was no reported treatment for Five months prior to presentation, she was seen by her gastroenterologist for altered bowel habit and new onset diarrhea with scant blood. She underwent a colonoscopy one month ago which only revealed mild diverticulosis. On admission, she reported having indigestion ongoing for several months and described it as bloating, early satiety, and anorexia. Two weeks prior to presentation, she developed abdominal distention with several episodes of severe nausea and bilious vomiting. The patient admitted to using aspirin/paracetamol/caffeine almost daily for the last 4 months for headaches. She reported stopping it for her colonoscopy ten days prior to admission.3, with a normal basic metabolic panel, lipase level, and liver function panel. Abdominal X-ray was unremarkable, and computed tomography (CT) of the abdomen . Her labs on admission were remarkable for leukocytosis to 17,700/mm abdomen  showed nH. pylori. Her magnetic resonance cholangiopancreatography (MRCP) was unremarkable for any pancreatic or duodenal abnormalities. An upper GI series  along with PPI. A follow-up breath test to check for eradication was negative.Two weeks later, on outpatient follow-up, an abdominal CT showed resolution of the gastric distention. Repeat EGD at three months showed diverticulum in the prepyloric region without any evidence of obstruction. Continued deformity of the prepyloric area and scarring from her previous PUD was noted. Patients' initial biopsies were negative for malignancy and positive for Gastric diverticula (GD) are rare congenital or acquired outpouchings of the gastric mucosa. Most are small and solitary 1–6 cm projections that go largely unnoticed, although cases of large 20 cm diverticula have been described with significant symptomatology. GD represent the least common variety of diverticular disease, with a prevalence ranging from 0.01%–0.11% on EGD, with 0.02% found on autopsy [Congenital GD account for upwards of 70% of all cases and classically arise on the posterior aspect of the lesser curvature, near the gastroesophageal junction . They arAcquired GD are less common pseudodiverticula that lack muscular layers and are generally found near the gastric antrum . They arGiven that symptoms can be extremely variable, a high index of suspicion is necessary to make the diagnosis. Most patients are largely asymptomatic and are diagnosed only by incidental findings on EGD. When present, clinical symptoms are nonspecific, ranging from abdominal fullness and anorexia to frank gastrointestinal bleed or perforation , 4, 7. MGD was historically diagnosed using barium swallow studies, and while contrasted CT may provide some diagnostic utility, quantitative comparison of imaging sensitivity has not yet been established. Direct visualization via EGD appears to offer the greatest utility, although a combination of imaging modalities is typically required, given its low incidence and nonspecific symptomatology , 7. In oTreatment tends to be proportional to clinical presentation, with asymptomatic diverticula often requiring no intervention . Mildly Although perforation and gastric tumors are both rare complications, their existence reaffirms the importance of prompt recognition and treatment of gastric diverticulum, especially in symptomatic cases. Our case represents an uncommon presentation of GD masquerading as gastric outlet obstruction, reinforcing the importance of including it in the differential when approaching cases with nonspecific abdominal findings unattributable to more common gastric pathology.


We report our experience in treating a ruptured dissecting posterior inferior cerebellar artery (PICA) aneurysm. To our knowledge, this is the first reported case of overlapping stenting without coils for a ruptured dissecting aneurysm of the proximal PICA. A 66-year-old male patient presented with sudden altered mental state and a subarachnoid hemorrhage (SAH). The cerebral angiography revealed a long segmental dissecting aneurysm on proximal PICA. Overlapping stents were deployed to the dissecting site, and angiogram showed intact distal PICA flow and decreased contrast staining in the dissecting site. Successful flow diversion was achieved with stents. Procedure-associated complications did not occur. The patient’s postoperative course was uneventful. In follow-up cerebral angiography, dissecting aneurysm achieved complete remodeling. The decision that led to the choice of treatment is discussed. Isolated spontaneous dissecting aneurysms of the posterior inferior cerebellar artery (PICA) are rare lesions ,5,6,7,8.We report our experience with treatment of ruptured dissecting PICA aneurysm. To our knowledge, this is the first reported case of overlapping stenting without coils for isolated ruptured dissecting aneurysm of the proximal PICA.A 66-year-old male patient presented with sudden altered mental status. On arrival at our hospital his Glasgow Coma Score was 12/15. The patient’s past medical history included diabetes mellitus, hypertension and angina pectoris. He had taken non-vitamin-K antagonist oral anticoagulant (NOAC) for underlying disease.The initial brain computed tomography (CT) scan revealed ventricular enlargement and diffuse subarachnoid hemorrhage at the perimedullary area with IVH at the third and fourth ventricle. For a differential diagnosis, CT angiography was performed and revealed a pearl and string pattern at the right proximal PICA. Then, the drainage of cerebrospinal fluid (CSF) was performed through external ventricular drainage via the Rt. Kocher’s point. Immediately after, cerebral angiography was performed. The right vertebral arterial (VA) angiogram revealed an approximately 10 mm-long segmental dissecting aneurysm on proximal PICA and large PICA vessels with PICA dominance over anterior inferior cerebellum artery (AICA) in supply of the cerebellum . On exteUnder general anesthesia, endovascular treatment was performed. Vascular access was obtained via the right common femoral artery. A 6-French guide catheter was placed in the right proximal VA, and a microcatheter was advanced distal to the tonsilomedullary segment of the PICA under guided microwire. An LIVS Jr.  woven stent was deployed to cover the entire dissection length to save the flow within the PICA. After 30 min, angiogram revealed inadequately decreased contrast staining in the dissecting site. Therefore, a second LIVS Jr. stent was deployed to overlap the stent using in-stent navigation by microwire. At 30 min after second stenting, angiogram showed an intact distal PICA flow and more decreased contrast staining in the dissecting site . SuccessThe patient’s postoperative course was uneventful. For 3 weeks, cerebral angiography and magnetic resonance (MR) imaging were performed. No evidence of infarction or stenotic lesion were identified upon examinations A. At disPICA dissecting aneurysms account for 0.5~0.7% of all intracranial aneurysms . Acute pNumerous vascular anatomic variations in VA and PICA with perforating vessels make a standardized approach difficult. Therefore, the management of PICA dissections remains controversial and challenging. Treatment of PICA dissection includes medical, surgical, and endovascular options. For patients who present with a PICA infarct, conservative treatment can be recommended if there are no obvious angiographic risk factors for hemorrhage, such as a pseudoaneurysm. For patients who are treated with anticoagulation, Tawk et al. recommend close follow-up and a repeat angiogram within 2 weeks of presentation . Only paSurgical treatment includes various options such as proximal clipping, trapping, and wrapping or resection with PICA end-to-end anastomosis, PICA-to-PICA side-to-side anastomosis, OA-to-PICA anastomosis or PICA reimplantation to the VA ,13,14,15The advantages of endovascular management include the avoidance of manipulation of the brain stem, cerebellar tissue and lower cranial nerves. Most of the endovascular treatments of PICA dissecting aneurysms have included proximal occlusion ,17,18. AIn some cases, flow-diverting stent (FDS) treatment was used in the dissecting aneurysm to produce good results . HoweverWe have not tried the preventive occlusion test. Affected PICA occlusion was expected to result in large infarction of the cerebellum due to the small size of both AICA and contralateral PICA. Therefore, proximal PICA occlusion was considered to be the last treatment option. Thus, if the pseudoaneurysm is located distally, a sacrifice of the PICA distal to its third segment  will be usually well-tolerated. Since no data are available on the angiographic signs to predict whether occlusion of the PICA would be tolerated, a preventive test occlusion is usually recommended . HoweverIn our patient, the dissecting aneurysm involved a relatively straight, long segment of the proximal PICA. Surgical treatment was difficult because of the patient’s premedical history, the long segment involvement, hypoplastic OA, and hypoplastic contralateral PICA as well as his being unsuitable for bypass. We had decided that deployment of overlapping stents using a flow-diverting effect in the dissecting site would result in a good outcome. This strategy did not completely eliminate the potential for risk of rebleeding; however, in the situation of an unestablished treatment of PICA dissecting aneurysm, overlapping stenting without coils can be considered as another option.Optimal treatment strategies for dissecting aneurysms of PICA have not yet been established. However, in cases where bypass surgery was unsuitable or in an expected large-territory infarction after occlusion of the parent artery, overlapping stenting without coils may be a useful option for straightened long-segment-involved dissecting aneurysm of proximal PICA.


Case Report. A nonfunctional AH was incidentally discovered in a 59-year-old morbidly obese female patient with a 10-year history of hypertension and thyroidectomy. An abdominal computed tomography (CT) scan showed a left suprarenal mass of ∼16 cm in diameter. While the patient had no clinical manifestations from the hemangioma, all laboratory tests were within the normal values with no indication of a functional adrenal tumor. The mass was removed by open left adrenalectomy. The microscopic histological examination revealed a laminated structure with wide blood-filled spaces with a central core of necrotic and hemorrhagic changes, characteristic of a cavernous AH with the presence of a rare Liesegang ring.  Adrenal cavernous hemangiomas (AH) are benign nonfunctional vascular tumors rarely discovered as incidental findings on imaging studies or autopsies. This study presents a single case report of AH with another rare finding of the Liesegang ring. Also, we reviewed 73 case reports of cavernous adrenal hemangioma to provide an overview of AH's clinical characteristics.  Although rare, AH should be considered as a differential diagnosis for adrenal masses. This is the first reported case of a cavernous AH with rare microscopic findings of the Liesegang ring. Benign vascular tumor-like growths are commonly seen in the liver and skin tissues. However, the presence of a vascular tumor, cavernous hemangioma, in the adrenal glands is a rare incidental finding often discovered on radiologic imaging  or autopsy . AdrenalUsually unilateral, AH is observed later in life (after the fifth decade) with female preponderance , 4. We rThere are about 73 case reports of AH available from the year 1955 to date. Evidence of Liesegang ring has been reported with fibrotic, cystic, necrosed, or inflamed tissue of the skin, conjunctiva, female genital tract, or kidney [A 59-year-old morbidly obese lady with a history of essential hypertension for ten years and hypothyroidism was referred to the urology department because of an incidental finding of a huge left suprarenal mass on the abdominal CT scan. The patient had no other complaints or clinical signs that may be attributed to adrenal  overactivity, and the physical examination had no abnormality. Laboratory tests, including urine tests for 24-hour fractionated metanephrine, were within normal limits.Pre- and postcontrast abdominal CT scans  revealedThe mass was removed through an open approach via a supraumbilical midline incision. It was well-circumscribed and has no signs of local invasion to the adjacent structures. The gross pathological examination showed an intact mass covered by a smooth and glistening capsule, measuring 16 × 15 × 10 cm and weighing 1.73 kg. On cut-section, the mass showed cystic areas with extensive hemorrhage and yellow areas, suggestive of necrosis. The residual adrenal gland could be identified .On histological examination, the specimen consisted mainly of infarcted, necrotic tissue with cyst-like vascular spaces that were expanded due to collection of blood and were lined by a single layer of mature endothelial cells, without atypia or mitosis. The stroma showed extensive fibrinous material in which many Liesegangs rings were observed. The rings were assembled in a lamellar fashion similar to psammoma bodies or a parasite egg . With an amorphous material in the middle, the central core was surrounded by a two-layered wall that stained negative with PAS and von Kossa . The annular structure was nonbirefringent when viewed under polarized-light microscopy, and on immunohistochemistry, the cystic lining tested positive for CD34 and CD31  is highly suggestive of AH , 21. FolThis review aimed to identify and systematically present the typical clinical features of the cavernous adrenal hemangioma to aid in diagnosis and treatment planning. Approximately 73 cases of cavernous AH have been published from 1955 through 2020 which were reviewed in the present study . The aven = 10) and pain or discomfort in the flank (n = 8), and 3 patients presented with rupture of the adrenal mass leading to retroperitoneal hemorrhage and hematoma [Of the 73 cases reviewed, 42 (57.5%) were discovered incidentally with no clinical symptoms, while the other 31 (42.5%) had clinical manifestations, including abdominal symptoms of epigastric pain and heaviness  had laparoscopic surgery. Of the two nonoperated patients, one patient died from an unrelated cause, while the other opted for monitoring and observation since the tumor size was small and no clinical manifestations were seen .5% had l.Lastly, mitotane, an established adrenolytic drug, was used in these patients that did not affect the viability of primary culture cells. However, cytotoxic drugs like doxorubicin decreased the viability of these cells. Furthermore, there is evidence that sunitinib, a multitarget tyrosine kinase inhibitor, drastically reduced the viability of the primary culture cells, indicating that the drug and its analogs may be useful in medically treating adrenal hemangiomas .Adrenal hemangioma should be considered as an important differential diagnosis of adrenal neoplasms despite being a rare finding. The treatment of choice remains surgical excision owing to the possibility of malignancy.


Sino-orbital aspergillosis is an uncommon but aggressive infection. It rarely originates from the frontal sinus due to the complex anatomy of the frontal recess and anteromedial position of its ostium. An 87-year-old man of Nigerian heritage with a history of multiple myeloma, chronic kidney disease and type 2 diabetes, presented to the eye clinic with a right tense swollen eyelid and proptosis. Computed tomography (CT) and magnetic resonance imaging (MRI) scan revealed a right superomedial mass communicating with the frontal sinus and biopsy confirmed an orbital aspergilloma. The patient was successfully treated with debulking surgery and anti-fungal treatment despite developing side effects to the drugs. To improve prognosis, ophthalmologists should be aware of this distinct entity and use a multi-disciplinary approach. Sino-orbital aspergillosis is a rare condition that is caused by an infection of the paranasal sinuses spreading to the orbit. It can be divided into: invasive  and non-invasive types . DiagnosPatient information: an 87-year-old Nigerian businessman presented to the eye clinic with a 3-week history of right orbital swelling. He divided his time between the United Kingdom and rural Nigeria. He had longstanding myeloma with previous bone marrow transplant in 2002 and had been on thalidomide derivative therapy for many years. He also had a background of chronic kidney disease (CKD) and well controlled type 2 diabetes mellitus (T2DM).Clinical findings: on examination, he had slightly reduced visual acuities  with no relative afferent pupillary defect, and known deuteranomaly. The right eyelid was very swollen and erythematous; his lids had to be pulled open for examination . Computerized tomography (CT) and magnetic resonance imaging (MRI) scan revealed a retro-orbital mass closely associated with the right lacrimal gland  amphotericin B, then switched to IV then oral voriconazole.Follow-up and outcome of interventions: a repeat scan a month later showed an improvement in proptosis and slightly less bulky aspergilloma. He could not have contrast due to poor renal function. The MRI and CT scans were discussed at our local radiology meeting, and it was thought the orbital mass was communicating with the right frontal sinus . He developed deranged liver function tests as well as experiencing nightmares on voriconazole and this was discontinued after 6 weeks of treatment. A lower dose of voriconazole was restarted to avoid renal toxicity.Patient perspective: the patient was initially anxious as he was unsure whether the swelling was related to his multiple myeloma. Once the swelling subsided, he felt reassured that his vision was unchanged. The treatment was the most challenging element, as he found the nightmares caused by the medication highly distressing, and was very happy when the course of antifungal medication was completed. To date, he has had no further recurrences.Informed consent: yes, consent given to use images for educational purposes only  and that all images will be cropped to only show the area of interest.Aspergillus spores are frequent contaminants of the respiratory tract, rendering it the most likely cause of fungal infection of the paranasal sinuses. A ball of aspergillus (known as an aspergilloma) is typically found in the non-invasive type, but may become invasive in immunocompromised patients . Sino-orIn our case report, the patient was immunocompromised with T2DM, multiple myeloma and CKD. He was initially thought to have a neoplastic lesion due to the MRI images and recent weight loss. Aspergilloma was diagnosed via histopathological examination of the biopsy. The origin of the infection was unclear. We postulate it arose from the frontal sinus due its location, mild frontal recess opacification on MRI scan, and possible communication. A limitation associated with this case report is that a sinus biopsy was not taken during endoscopy.Sino-orbital aspergillosis most frequently arises from the maxillary sinus, followed by the ethmoid, sphenoid and rarely frontal sinuses -7. The lIntraoperative findings of friable cheesy-like material that is green, yellow, brown or black are in keeping with a fungus ball. The diagnosis is typically confirmed by microscopic detection of fungal material, such as dichotomous, branching hyphae in smear. Debulking along with prolonged antifungal therapy can be effective in controlling the infection; in addition to retrobulbar amphotericin B injection . Our casInvasive sino-orbital aspergillosis is an aggressive disease and may be misdiagnosed as a tumor. We present a rare case likely arising from the frontal sinus. To improve prognosis, ophthalmologists should be aware of this distinct entity and use a multi-disciplinary approach.


Hydrocele of canal of Nuck (HCN) is a rare disease in adult female. The diagnosis and treatment of HCN is still a challenge for surgeons.A 56-year-old female presented with recent onset of occasional pain during exercise and an asymptomatic left groin swelling. Ultrasonography results were suspicious for left inguinal hernia incarceration and computed tomography (CT) scan showed no intestinal obstruction, which was considered as HCN. Laparoscopic hydrocelectomy of the HCN and a routine laparoscopic hernia repair via the transabdominal preperitoneal (TAPP) approach were performed. Postoperative pathology showed no malignant lesions or endometriosis.The preoperative diagnosis of HCN is extremely important. Surgeons should choose appropriate surgical methods for different anatomical HCNs based on the preoperative diagnosis. Hydrocele of canal of Nuck (HCN) is a very rare disease in adult female , most ofA 56-year-old female patient on dialysis presented with swelling of the left inguinal area which was aggravated during activities and suspected to be an inguinal hernia. Palpation revealed that the left groin mass could not be returned to the abdominal cavity. Ultrasound results of the lower groin (US) was suspect for intestinal obstruction Fig. a, b. HowUnder general anesthesia, a 12-mm trocar was inserted through the umbilical incision, and two 5-mm working ports were placed symmetrically. The internal inguinal ring was relatively weak  have become progressively more popular methods , 22. HowEven though laparoscopy has so many advantages, it is difficult for the laparoscope to successfully free the distal end of the HCN if the inguinal canal is deep or the HCN is too huge . At thisThe preoperative diagnosis of HCN is extremely important. Surgeons should choose appropriate surgical methods for different anatomical HCNs based on the preoperative diagnosis.


Retroperitoneal (RP) leiomyosarcoma (LMS) is a rare type of cancer, accounting for 0.1% of all malignancies. The gold-standard treatment for sarcoma is complete resection, and a 50% 5-year overall survival (OS) rate can be achieved by curative surgery. The survival benefits of radiotherapy and systemic chemotherapy for recurrence are not as good as those of surgical resection. To the best of our knowledge, there are a few reports that aggressive radical surgery significantly prolonged the survival period as our case. This case was reported in accordance with the SCARE 2020 Guideline (Ref).An 84-year-old woman was referred to our hospital for treatment of a primary RP tumour. At the age of 52-year-old, she underwent complete resection of an RP mass in 1991. Twenty-four years after the primary resection, metachronous recurrences occurred within the soft tissues, which were repeatedly resected. From 2015–2019, liver resections were performed thrice, and the patient survived with no signs of recurrence 1 year after the last surgery.Long-term survival of 29 years was achieved after undergoing over 20 surgical resections. Herein, we report the long-term survival of a patient who underwent repeated aggressive surgical resections for RP LMS recurrence anda literature review. The gol2An 84-year-old woman was referred to our hospital for treatment of a primary RP tumour. At the age of 52, the patient underwent complete resection of a mass, approximately 3 cm at RP in 1991. The pathological diagnosis was LMS. Twenty-four years after the primary resection, metachronous recurrences occurred within the soft tissues, which were repeatedly resected. The recurrence sites were as follows: psoas muscle, latissimus dorsi muscle, deltoid muscle, and chest wall. As the tumours within the soft tissues felt stiff upon palpation, these tumours were easily detected by the patient. Ten recurrences occurred in the extremities, two in the retroperitoneum and three in the back. The chest wall was also involved twice, but both were completely resected. In 2015, multiple liver metastases were identified. Computed tomography(CT) showed that the tumour was located in segments 4, 5, 6, and 8. The whole tumour was enhanced in the early phase, and the enhancement was prolonged in the late phase A–C. Etho3Metastasis after curative surgery for LMS occurs in approximately 40% of cases, and the most frequent site of metastasis is the lung via the hematogenous route. Our patient had more than 20 metachronous recurrences, and long-term survival was achieved by undergoing repeated aggressive surgeries. Except for three liver metastasis cases, all metastatic lesions were detected at the late stage, which we found on the extremities and back muscles. R0 resections were then repeatedly performed for metastasis. Previous studies have demonstrated that R1/2 resection is an independent risk factor for recurrence-free survival in patients with LMS ,9. MarudThe benefits of surgical resection for extrahepatic metastasis remain unclear; the incidence of local recurrence was reported to be approximately 50%, while that of distant metastasis was approximately 40% after curative surgery . Lang etUntil now, the efficacy of systemic chemotherapy for the recurrence of LMS remains unclear. Chemotherapy consisting of cyclophosphamide, doxorubicin, and dacarbazine is considered for patients with unresectable or distant metastases, but these patients' prognosis remains poor. Recent retrospective studies have demonstrated that chemotherapy administration in combination with surgery preoperatively or postoperatively may result in a worse survival outcome compared with surgery alone. Some cases have shown that systemic chemotherapy prolongs long-term survival . In someDeciding whether to resect for recurrent cases and the timing of resection with the possibility of concomitant non-surgical treatment (such as radiation or systemic therapy) can be difficult. Surgery in patients with recurrent RPS can be more technically challenging than surgery in patients with primary disease. Adhesions in the intestine and other parts of the body often need to be resolved, which increases the risk of complications, such as intussusception and postoperative ileus. In general, each recurrence of RPS is associated with a lower complete resection rate and worse clinical outcomes. Therefore, it is important to appropriately select patients with recurrent RPS expected to benefit the most from re-resection. Important considerations favouring re-resection include R0 resection, low-grade tumours, a disease-free interval, and unifocal rather than multifocal local disease .Even in cases where R0 resection is not possible, resection for symptomatic relief may be considered, but take into account the fact that systemic chemotherapy may be interrupted. The duration of symptomatic relief has been reported to be short The decision-making process for palliative RPS resection is complex, and cases should be discussed among multidisciplinary team members.In conclusion, repeat R0 surgery for RP metastases can provide long-term survival of 30 years after the primary surgery. Regardless of the lack of an established treatment strategy for recurrent RP metastases, aggressive surgical resection should be considered in patients with resectable RP metastasis.The authors report no declarations of interest.No.This paper has been granted ethical approval.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Nao Kitasaki is the first author, and Tomoyuki Abe is a corresponding author.Nao Kitasaki, Tomoyuki Abe and Akihiko Oshita contribute the study concept and design.Nao Kitasaki, Tomoyuki Abe, Shuji Yonehara, Toshio Noriyuki and Masahiro Nakahara contribute the data collection, data analysis and interpretation.Nao Kitasaki, Tomoyuki Abe, Tsuyoshi Kobayashi and Hideki Ohdan contribute the witing the paper.Not applicable.Tomoyuki Abe.Not commissioned, externally peer-reviewed.


Adult intestinal malrotation with midgut volvulus is rare and most often diagnosed on abdominal imaging. Once the diagnosis is made, prompt surgical intervention is necessary. A finding suggestive of malrotation with midgut volvulus on abdominal imaging is the “whirlpool” sign where the superior mesenteric vein and superior mesenteric artery twist at the root of the abdominal mesentery. This sign was once thought to be pathognomonic, but recent studies have shown that it can be seen in asymptomatic patients.A 20-year-old female presented to our emergency department with diffuse abdominal pain. Computed tomography demonstrated the “whirlpool” sign with a concern for malrotation with midgut volvulus. Surgical consultation was obtained and the patient was rushed to the operating room for an exploratory laparotomy. Normal mesenteric attachments were seen and no significant pathology was identified during the laparotomy. The patient was eventually diagnosed with gastritis and discharged in stable condition.Emergency physicians and surgeons alike should be cautious in confirming malrotation with midgut volvulus solely due to the “whirlpool” sign on abdominal imaging. Premature diagnostic closure can lead to unnecessary procedures and interventions for patients as in the case we report here. Malrotation with midgut volvulus is an uncommon surgical emergency in adults. The diagnosis is established with certain characteristic findings on computed tomography of the abdomen and pelvis (CT A/P). The most notable finding is a counterclockwise twisting of the superior mesenteric vein (SMV) onto the superior mesenteric artery (SMA), also known as the “whirlpool” sign.Our patient was a 20-year-old female who presented to the emergency department (ED) with two hours of diffuse abdominal pain. She had similar episodes of abdominal pain in the past that occurred once or twice a year after food intake, which were relieved with pain medication. On current presentation, her pain was far worse than usual.Initial vitals were unremarkable, without tachycardia and without fever. Upon examination, the patient’s abdomen was soft but diffusely tender from the epigastrium to the hypogastrium. She exhibited no guarding or rebound tenderness. Her laboratory studies included an unremarkable chemistry panel, a slight leukocytosis of 11.3 thousand cells per microliter (K/μL) (reference range: 3.9 – 11 K/μL), and a normal serum lactate of 0.76 millimoles per liter (mmol/L) . An upright chest radiograph did not demonstrate pneumoperitoneum. Intravenous morphine and famotidine were administered with minimal relief of symptoms. Computed tomography of the abdomen and pelvis (CT A/P) with oral and intravenous contrast demonstrated a distended stomach, a duodenum that did not definitively cross midline, mildly dilated small bowel loops that were mostly in the right lower quadrant and, most distinctively, an SMV that twisted in a 360° counterclockwise fashion to the left of the SMA. A presumed diagnosis of malrotation and midgut volvulus was made and prompt surgical consultation was obtained.The patient was taken emergently to the operating room for an exploratory laparotomy. The bowel was found to be in its proper anatomic position with normal peritoneal attachments and without the presence of any Ladd’s bands.  On postoperative day one the patient underwent an upper endoscopy, revealing erosions and erythema in the stomach and superficial duodenal ulcers. Her postoperative recovery was unremarkable, and she was discharged home uneventfully with the diagnosis of gastritis and peptic ulcer disease.Malrotation is a condition resulting from an embryologic abnormality: failure of the bowel to rotate in a 270° counterclockwise fashion and fixate on the posterior abdominal wall. Without this fixation, the small bowel can twist about the base of its mesentery onto the large bowel, resulting in a midgut volvulus. Classically, this condition presents in infancy, with 90% of cases occurring under the age of one. Only 0.2–0.5% of cases of intestinal malrotation occur in adulthood, and of these cases only 15% present with a midgut volvulus.3A finding previously considered to be pathognomonic6What do we already know about this clinical entity?Malrotation with midgut volvulus is a condition requiring timely diagnosis in the emergency department and may be present at any age. It should not be thought of as a strictly pediatric problem.What makes this presentation of disease reportable?Malrotation with midgut volvulus will be suggested by findings on computed tomography including a counterclockwise twisting of the superior mesenteric vein on the superior mesenteric artery.What is the major learning point?Caution must be used when interpreting the above “whirlpool” sign as it is not necessarily pathognomonic of malrotation as was previously thought.How might this improve emergency medicine practice?Emergency physicians should not just rely on the finding of the “whirlpool” sign to diagnose malrotation and should consider all clinical and radiographic data available.Our patient ultimately did not have malrotation with midgut volvulus despite radiographic findings suggestive of malrotation including a positive “whirlpool” sign, gastric distention, and most of the small bowel loops in the right lower quadrant. She did not have any laboratory findings suggestive of ischemia.Her presentation was suggestive of malrotation but can also be explained by peptic ulcer disease or other upper gastrointestinal causes of pain. Our patient’s case illustrates the point that a “whirlpool” sign is not in itself pathognomonic for malrotation and can be a normal variant, and that clinical correlation is key to determining indications for operative intervention. Rather than surgical intervention in this case, continued observation with serial abdominal exams with possible endoscopic intervention or an upper GI series could have been pursued.Malrotation with midgut volvulus is an important condition requiring timely diagnosis in the ED and may be present in all age groups. It should not be thought of as a strictly pediatric problem. Very often, the diagnosis will be suggested by findings on a CT of the abdomen/pelvis including a counterclockwise twisting of the superior mesenteric vein on the superior mesenteric artery. Caution must be used when interpreting this “whirlpool” sign, as it is not necessarily pathognomonic of malrotation as was previously thought.