Colonoscopy is a routine procedure performed worldwide, nevertheless, a small risk of splenic injury, often under-estimated, is still present. As a matter of fact, the diagnosis may be delayed, leading to a rising risk of morbidity and mortality. This paper describes a case of conservative treatment of colonoscopy-associated splenic injury.A 57-year-old woman presented with worsening pain in the upper left abdominal quadrant; she had radiation therapy to the ipsilateral subscapular region, and a diagnostic colonoscopy 18 hours earlier.The computed tomography (CT) scan revealed splenic laceration without signs of hemoperitoneum. Because of the hemodynamic stability of the patient, successful conservative treatment and serial controls of the blood and hemodynamic parameters were adopted.Even if rare splenic injury during colonoscopy is associated with significant morbidity and mortality. A high degree of clinical suspicion is essential to achieve a prompt diagnosis as well as an early surgical evaluation.The nonoperative approach is usually taken in patients with no intraperitoneal bleeding, a closed subcapsular haematoma and a stable hemodynamic status. Colonoscopy is commonly performed for diagnosis and treatment of benign and neoplastic pathology, as well as for colorectal cancer screening . AlthougHere we report a case of splenic haematoma after colonoscopy that was managed conservatively and successfully.A 57-year-old woman, already undergone several years ago to hysterectomy for multiple leiomyomas and laparoscopic cholecystectomy, came to our observation for worsening pain in the upper left abdominal quadrant, with radiation therapy to the ipsilateral subscapular region.The patient underwent, about 18 hours before, to diagnostic colonoscopy in analgosedation for evaluation of chronic anaemia. The colonoscopy was uneventful and did not reveal a cause of her chronic anaemia.Before colonoscopy, her haemoglobin was 10.8 g/dL and systolic blood pressure 120 and 85 mmHg with 76 beats/minute. The patient did not report enterorrhagia, hematemesis or melena.In our examination the abdomen was soft, systolic blood pressure was 110/80 mmHg with 88 beats/minute; the haemoglobin was 9.5 g/dL and the ultrasound (US) examination was not diagnostic for the splenic injury because of the intestinal meteorism.The computed tomography (CT) scan revealed grade II splenic laceration without signs of hemoperitoneum where the anterior capsule of the spleen was noted to be densely adherent to the splenic flexure of the colon and partially avulsed Figure .The patient was promptly hospitalized and conservative treatment was undertaken. The hemodynamic parameters remained stable, the pain was reduced in intensity and the US control did not show the hematoma increase in dimension. The patient was discharged after three days and the eight-month follow-up showed the complete resorption of the haematoma without remnants.In a systematic review of 12 studies including 57,742 screening colonoscopies, the rate of serious adverse events was found to be as low as 0.28% . AnotherSplenic injury after colonoscopy procedure is rare but a serious complication. From 1974 to 2012, a total of 103 cases have been reported . JehangiThe overall incidence of splenic injuries ranges from 1 in 100,000 to 1 in 6,387 colonoscopies [In the US, we estimate that in 2004 we performed 22.4 million colonoscopies . So takeThe mechanism for splenic trauma during colonoscopy is yet to be fully understood - postulation is the excessive traction on the splenocolic ligament and/or on splenocolic adhesions, secondary to previous abdominal surgery or intraabdominal inflammatory processes, or a direct blunt trauma when navigating the colonoscope through the splenic flexure ,6.Known risk factors for splenic trauma also include older age, less experienced endoscopists, being female, polypectomy and biopsies during the procedure ; other cPreventive measures are good colonoscopy technique to avoid loop formation and left lateral position of the patient to reduce the risk of splenic injury after colonoscopy . The useNearly 67% of patients presented within 24 hours of colonoscopy with complaints ranging from abdominal pain to dizziness. The most common symptom is left upper quadrant pain (95%), and CT scan was found to be the most sensitive and specific tool for diagnosis (98.5%) and grading the extent of splenic injury. Abdominal pain either generalized or in left upper quadrant is the chief complaint in most patients (85%), only 15% presented with signs of hemodynamic instability such as dizziness and syncope [According to the American Association for the Surgery of Trauma (AAST), splenic injuries are classified as grade I - subcapsular hematoma <10% of surface area, capsular laceration <1 cm depth; grade II - subcapsular hematoma 10-50% of surface area, intraparenchymal hematoma <5 cm in diameter, laceration 1-3 cm depth not involving trabecular vessels; grade III - subcapsular hematoma >50% of surface area or expanding, intraparenchymal hematoma >5 cm or expanding, laceration >3 cm depth or involving trabecular vessels, ruptured subcapsular or parenchymal hematoma; grade IV - laceration involving segmental or hilar vessels with major devascularization (>25% of spleen); grade V - shattered spleen, hilar vascular injury with devascularized spleen .In Piccolo et al. review of the literature only 24% of cases were managed conservatively while 70% was treated by splenectomy as a definitive management . Severe Colonoscopy is a safe procedure hardly ever burdened by splenic injuries, therefore their management is independent from the colonoscopy indication. Nevertheless, the treatment of this complication should be tailored on the type of injury, reserving the surgical approach to unstable patients with spleen rupture, which leads to a significantly higher mortality rate.


Rosai-Dorfman disease (RDD), or sinus histiocytosis with massive lymphadenopathy, is a rare non-Langerhans cell histiocytosis. We report a case of a 69-year-old male with concurrent appendiceal and rectal masses who underwent CT-guided percutaneous biopsy. Histopathology confirmed a diagnosis of RDD with IgG4-positive plasma cells. It is believed to be a subset of RDD that shares similar features with IgG4-related disease suggesting some overlap of the two diseases. Because gastrointestinal RDD accounts for less than 1% of extranodal disease, it is important to recognize this entity in order to guide management. We review the presentation, diagnosis, and treatment of gastrointestinal RDD and discuss the possible overlap with IgG4-related disease. Rosai-Dorfman disease (RDD), also known as sinus histiocytosis with massive lymphadenopathy, is a rare non-Langerhans cell histiocytosis, first observed in 1965 by Destombes and established as a clinicopathological disease by Rosai and Dorfman in 1969 . The preμg/dL and ferritin of 3.3 ng/mL, confirming a diagnosis of iron deficiency anemia. CT of the chest, abdomen, and pelvis with intravenous contrast was performed to evaluate for occult malignancy.We report the case of a 69-year-old male with a past medical history of hypertension, coronary artery disease, ischemic cardiomyopathy, noninsulin dependent type 2 diabetes mellitus, and alcohol dependence who presented to our institution in cardiac arrest and underwent emergent cardiac catheterization. During admission, laboratory results were notable for anemia with a hemoglobin of 4.6 g/dL, compared to a baseline hemoglobin of 14.2 g/dL approximately four years prior, with mean corpuscular volume of 65 fL. Further workup revealed iron levels of less than 10 While chest CT did not show any findings of intrathoracic malignancy, abdomen and pelvis CT showed a 2.4 × 3.2 cm soft tissue mass at the tip of the appendix  as well A colonoscopy was performed with a normal appearing appendiceal orifice and normal rectal mucosa without any masses identified. The patient also underwent a flexible sigmoidoscopy with endoscopic ultrasound evaluation of the rectum. No rectal mass was seen on endoscopic ultrasound, and only small, benign appearing perirectal lymph nodes were identified and therefore, no biopsies were obtained.Carcinoid tumor was in the differential in addition to malignancy. However, serologic studies showed normal gastrin (39 pg/mL), chromogranin A (2 nmol/L), and serotonin (86 ng/mL) levels. Given the presence of concurrent appendiceal and rectal masses, tissue sampling was further pursued for treatment planning. Three 18-gauge  core neeHistologic sections showed a heterogeneous lesion composed predominantly of histiocytes with numerous scattered plasma cells and lymphocytes . Many ofThe patient was discharged in stable condition and with an outpatient referral to an oncologist and a histiocytosis specialist at an outside institution. We were unable to obtain further workup or treatment.Rosai-Dorfman disease is an idiopathic proliferation of non-Langerhans cell histiocytes presumed to be a reactive inflammatory process . AlthougGastrointestinal RDD causes subacute symptoms with gradual progression, typically in middle-aged females . PatientDiagnosis of RDD can be made based on clinical history and histopathologic evaluation. Large histiocytes with abundant eosinophilic cytoplasm are characteristic of RDD with large hypochromatic nuclei and prominent nucleoli. The presence of emperipolesis (lymphocytophagocytosis) is helpful but not necessary for diagnosis. Emperipolesis can also be seen in Erdheim-Chester disease, Juvenile xanthogranuloma, or even malignant histiocytosis. On immunohistochemistry, histiocytes in RDD are positive for S100 and CD68, with variable positivity in CD163 and CD14 . While tThere is no systematic approach to determining treatment for RDD. 20-50% of cutaneous or nodal RDD cases are self-limited , 8. SurgOur patient presented due to an acute coronary event with iron deficiency anemia and had incidentally detected multifocal gastrointestinal masses found on imaging, involving the appendix and rectum, with borderline enlarged pelvic and perirectal lymph nodes. A gastrointestinal malignancy with metastasis was initially the primary consideration. Despite distinctive soft tissues masses seen on CT and MRI, interestingly, the rectal mass was inconspicuous on endoscopic ultrasonography. This suggests that caution should be taken when using ultrasonography to evaluate disease. Additionally, it is likely that inflammatory changes related to RDD in the periappendiceal and perirectal soft tissues mimicked soft tissues masses on certain imaging modalities. Given the multifocal involvement, a percutaneous core biopsy of the lesion, rather than surgical excision, was performed for treatment planning. While only the appendiceal mass was biopsied, the perirectal soft tissue mass was felt to represent the same fibroinflammatory lesion based on imaging and clinical findings. Pathologic findings were typical for RDD with increased IgG4 plasma cells. Further studies are needed to evaluate significance of IgG4 plasmacytosis and delineate an algorithm for treatment.


Bilateral jugular foramen stenosis with jugular bulb and vein aplasia is rare in nonsyndromic craniosynostosis and usually diagnosed during childhood. We present a case of bilateral jugular foramen stenosis with jugular bulb and vein aplasia, with subsequent persistence and enlargement of the fetal venous anastomosis in the middle and posterior cranial fossa, along with a review of the literature about this anatomical abnormality, highlighting the surgical challenges and management from the otologist/neurotologist point of view. Internal jugular vein (IJV) drains blood from the head and neck region and is a major contributor to venous drainage from intracranial structures .Emissary veins (EV) are valveless veins that pass through cranial openings, complementing the IJV in the extracranial venous drainage of the posterior fossa dural sinuses . They reThe prevalence of the major posterior fossa EV is not low in the general population , being uEV may be enlarged in the event of high-flow vascular malformations or in severe IJV aplasia or thrombosis, as they became the only pathway for draining the blood from the posterior fossa, converting the external jugular vein to the foremost encephalic outflow pathway .EV may be of clinical importance to otologists not only because they may present with pulsatile tinnitus but also because they may cause a significant intraoperative bleeding or postoperative sinus thrombosis , 7. FurtWe present a case report of bilateral jugular foramen stenosis with jugular bulb and vein aplasia and review the literature about this anatomical abnormality, highlighting the surgical challenges and management from the otologist/neurotologist point of view.A 40-year-old woman presented in our hospital with a 10-year bilateral progressive hearing loss. She had been diagnosed with bilateral otosclerosis at another hospital.The patient had an unspecified head surgery during childhood but no other relevant medical history, namely no history of noise trauma, ototoxic drugs, or relevant familiar history.She had a normal otologic and head and neck examination with no syndromic features.Audiology testing revealed a mild bilateral mixed hearing loss (15 dB mean air-bone gap), an ipsilateral type as tympanogram bilaterally and absent ipsilateral acoustic reflexes.A preoperative high-resolution computed tomography (HRCT) scan was suggestive of bilateral superior semicircular canal dehiscence and showed a bilateral jugular bulb and foramen aplasia, a persistent petrosquamous sinus, and multiple vascular impressions in the middle cranial fossa, the latter causing a tortuous tubular images projecting in the proximity of the temporomandibular joints and separated from the superior and posterior wall of the external ear canal by only a thin bony lamella Figures .Further imaging with magnetic resonance venography (MRV) showed a right dominant transverse and sigmoid venous sinus, a bilateral internal jugular bulb, and vein aplasia. It further identified a bilateral persistent petrosquamous sinus , a posterior condylar emissary vein , a mastoid emissary vein (draining into the posterior auricular vein and mastoid foramen) and an occipital emissary vein  Figures .Both cervical and ocular vestibular evoked myogenic potentials were normal.The patient refused any otological treatment. Furthermore, since there were not any other neurologic symptoms or signs, no further management was needed.Jugular and sigmoid sinus are relatively narrow, reaching adult size only two years after birth, probably as a result of haemodynamic factors caused by the adoption of an upright posture. Until then, EV play a role complementing the IJV system with most disappearing as sigmoid sinus and jugular vein grow, as discussed by Jeevan et al. .However, EV can persist and be abnormally enlarged due to failure of normal maturation of the sigmoid-jugular complex (SJC). The cause for this anatomical abnormality is still unknown. According to Jeevan et al. , while oThere are few case series reporting EV in patients with craniofacial syndromes, with Jeevan et al.  reportinIn the present case, the vascular abnormality was incidentally found during a preoperative temporal bone CT imaging in an adult patient. We presume that the patient is a nonsyndromic craniossynostosis, as there is an irregular thickness in the calvarium contour suggestive of a previous cranioplasty eventually due to a craniosynostosis, but no syndromic features .CT scans revealed a jugular foramen stenosis and prompted further study of venous anatomy with MRV and 3D reconstructions. The latter showed a jugular bulb and vein aplasia and subsequent persistence and enlargement of the fetal venous anastomosis in the middle and posterior cranial fossa. These reconstructions are helpful for visualising foramen patency and specific routes of emissary drainage, although CT venography can also be reliable in depicting the intracranial venous circulation with high quality, with the disadvantage of radiation exposure , 12.Mastoid emissary vein, posterior condylar vein, petrosquamosal sinus, and occipital emissary vein are the major posterior fossa emissary veins. Mastoid emissary vein originates from the sigmoid sinus and drains into the posterior auricular or occipital vein. Posterior condylar vein arises from the jugular bulb and drains into the deep cervical vein connecting also with the vertebral artery venous plexus. Occipital emissary vein arises from the transverse sinus and drains to the occipital vein and internal vertebral plexus. Petrosquamosal sinus arises from the transverse or sigmoid sinus and drains either into the retromandibular vein or into the pterygoid venous plexus , 8. DeteOur patient had hypoacusia and no other morbidities related to this anatomical variation, so no further management was offered. The patient further refused any surgical approach or hearing rehabilitation.In cases where surgical management is warrant , EV may present as a surgical challenge, as they may lead to a dramatic bleeding due to their large diameter , 14. AccIf in small and medium diameter EV, using electrocautery or plugging EV foramen with absorbable hemostatic material or bone wax seem an appropriate method of hemostasis, in large EV it may be necessary a free graft of connective tissue  plug, suture ligation of the vein (after being skeletonized through drilling), or a pedicled flap (indented into the EV foramen) .The different approach to different EV sizes may be justified by the increased risk of bone wax migrating into the lateral sinus, especially in abnormally dilated, short, and straight EV. Additionally, unipolar electrocautery can be contraindicated in the presence of implanted electronic devices, namely cochlear implants , 15.In conclusion, we present a case of a bilateral jugular foramen stenosis associated with a persistence and enlargement of the fetal venous anastomosis in the middle and posterior cranial fossa. This was incidentally diagnosed with imaging studies in an asymptomatic adult patient with a presumed nonsyndromic craniosynostosis. The thorough knowledge of these anatomical abnormalities is essential for a correct diagnosis as well as for the otological surgical preoperative planning and management of intraoperative complications.


Perineal hernia is a type of pelvic floor hernia and an extremely rare pathologic state. Perineal hernias can be classified into anterior and posterior types according to their positional relationship to the superficial transverse perineal muscle. A 49‐year‐old woman presented with bulging of the right labium major while standing. Standing external ultrasonography revealed a mass in the bulge, which could not be identified by transvaginal ultrasonography, CT, or MRI. Although hernia content could not be identified preoperatively, the patient was given a diagnosis of primary perineal hernia and underwent laparoscopic repair. Symptoms resolved postoperatively, and no sign of relapse has been noted for 8 months postoperatively. Here, we report the case details and review previous case reports. She consulted our hospital because the discomfort had recently progressed to pain while standing. On presentation, a thumb tip‐sized mass was seen in the right labium major on standing and disappeared on lying down. There was no tenderness, but she had mild pain at the site when increased intra‐abdominal pressure occurred such as during defecation. She had never been pregnant. Her medical history included an 8‐cm uterine myoma diagnosed at age 45 years for which she was being observed.For 5 months before presentation, a 49‐year‐old woman (BMI, 18.7 kg/mWhen the patient was in a standing position, bulging of the right labium major was noted with a palpable mass Figure . StandinAlthough the hernia content could not be identified, the mass was diagnosed as a primary acquired anterior perineal hernia, and laparoscopic repair was performed. A 2‐cm hernial orifice was found in the pouch of Douglas; the lumen extended toward the perineal region as confirmed by insertion of forceps into the orifice Figure . The her3Pelvic floor hernia is rare, and perineal hernia is an extremely rare pathologic state that surgeons might encounter once in their career,Perineal hernia mainly occurs secondary. Many secondary perineal hernias occur after perineal gland operation within 1 year of the antecedent surgery.Anterior perineal hernia occurs in the triangle‐shaped urogenital diaphragm surrounded by the ischiocavernosus, bulbocavernosus, and superficial transverse perineal muscles, and it affects only women.Clinical diagnosis of perineal hernia can be made using sonography, CT, MRI, and herniographyVarious approaches using mesh for closure of the pelvic defect have been reported for perineal hernia surgical repair, but the ideal approach has yet to be established. Sorelli et al recently reported THE advantages of the laparoscopic approach in perineal hernia repair.Table We reported this very rare case of primary acquired anterior perineal hernia as we believe it was a valuable clinical experience worth sharing.The authors have no conflicts of interest to disclose and received no funding for this report.This study received institutional review board approval, and it conforms to the provisions of the Declaration of Helsinki. The subject gave informed consent, and patient anonymity was preserved. Click here for additional data file.


Spontaneous rupture of benign uterine fibroids is extremely rare and has been associated with fibroid degeneration. It can cause acute intraperitoneal bleeding requiring immediate surgical intervention.  A previously healthy 50-year-old, Caucasian, nullipara presented with syncope, hemodynamic instability, and an acute abdomen. Noncontrast computed tomography images showed a positive sentinel clot sign in the pelvis as well as a large uterine fibroid with internal hyperdense clot suggesting acute rupture. Urgent laparotomy and hysterectomy confirmed a ruptured, actively bleeding, uterine fibroid with final pathological diagnosis of a benign leiomyoma.  Prompt diagnosis and emergency surgical intervention were necessary to control acute hemorrhage from a ruptured uterine fibroid. Noncontrast computed tomography is an important adjunct to contrast-enhanced computed tomography and was vital for diagnosis in this case. Leiomyomas are common benign tumors and can undergo degeneration. Rupture of degenerated uterine leiomyomas to cause acute intraperitoneal hemorrhage is extremely rare with only case reports in the literature so far –10. The We present a case of a spontaneously ruptured benign uterine leiomyoma, without significant degenerative change, causing hemodynamic instability. Our case demonstrates the important role of noncontrast computed tomography (CT) and the imaging features of acute hemorrhage from a uterine fibroid that allowed for the prompt diagnosis of this rare but life-threatening event.A 50-year-old nulliparous, premenopausal, previously healthy Caucasian woman presented to the emergency department with syncope, severe abdominal pain, and hypotension (blood pressure 80/40). Her symptoms began with rectal pressure. She bicycled to work as part of her normal morning routine. There was otherwise no history of trauma, intercourse, malignancy, abdominal surgeries, or known infection prior to presentation. Her past medical history included prior knee surgery and an umbilical hernia. She was not on any medications. There was a known history of a 7.5 cm fibroid incidentally found on a previous CT scan for evaluation of the umbilical hernia one year prior. Her menstrual cycles were regular, and she denied any history of abnormal PAP tests or sexually transmitted infections.On examination, the patient had normal BMI. Her abdomen was peritonitic and actively distending over time with fluid resuscitation and packed red blood cell transfusion. Other than hemoglobin of 98 g/L, a complete blood count and comprehensive metabolic panel was within normal limits. The quantitative HCG was negative. A bedside ultrasound at the time of presentation by the emergency physician showed free fluid in her abdomen.An emergency CT of the chest and abdomen was performed. Findings included moderate to large volume dense-free fluid (30 Hounsfield units) throughout the abdomen in keeping with large volume hemoperitoneum . NoncontExploratory laparotomy was undertaken and confirmed the imaging diagnosis. A large volume of blood and clots was found in the peritoneal cavity. An approximately 9 cm mass at the posterior aspect of the uterus was ruptured and actively bleeding . The resPathological examination of the panhysterectomy specimen showed a 13 × 9 × 9 cm uterus with a benign uterine leiomyoma. The large mass seen on imaging was a 10.5 cm subserosal cellular uterine leiomyoma with fresh hemorrhage. On light microscopy, the leiomyoma was highly cellular but circumscribed without cytologic atypia, mitotic activity, or necrosis. It did not have significant degenerative changes. There was an intratumoral blood tracking to the uterine serosal surface. There was also evidence of previous subclinical bleeding with intratumoral hemosiderin-laden macrophages . There wUterine leiomyomas are common benign tumors in women; however, complications resulting in acute hemoperitoneum are extremely rare. Large intraperitoneal hemorrhage from leiomyomas has been reported as a result of ruptured surface subserosal veins , 9. DegeThe leiomyoma in this case was highly cellular on pathologic examination. It is possible that there was less stromal support and decreased tissue integrity. We speculate that there may have been a hemorrhage from small vessels within the fibroid that breached the tissue integrity and thus precipitated a rupture from within the mass. Whether this was immediately prior to the spontaneous rupture or a process that has been ongoing for a period of time with enlargement of the fibroid could not be determined.Of note was the incidental finding of a small intramucosal endometrial adenocarcinoma in the uterus. It is unlikely to have contributed to the rupture as the leiomyoma was not involved. The leiomyoma had no pathologic findings of malignancy.Various imaging modalities such as ultrasound, CT scan, and magnetic resonance imaging (MRI) have been used for evaluation of ruptured leiomyomas in previous case reports . The acuThe lack of significant provoking factors, the acute onset large volume hemoperitoneum, and the lack of leiomyoma degeneration make our case unusual. In addition, we emphasize the importance of noncontrast CT scan images in promptly diagnosing the rupture and assisting surgical planning.This case report describes that uterine fibroids can spontaneously rupture, without significant degeneration, to cause acute hemoperitoneum and require immediate explorative laparotomy and hysterectomy to control the hemorrhage. Noncontrast computed tomography is required to accurately visualize clotted blood, which is hyperdense, in the pelvis. Hyperdense collections of clotted blood, known as the “sentinel clot sign”, may be missed on contrast-enhanced studies due to its similar attenuation to enhancing myometrium and collapsed bowel wall on contrast-enhanced images.


Superior sulcus tumors (SSTs) are a wide range of tumors invading a section of the apical chest wall called the thoracic inlet. The unique characteristics of SSTs lie in the anatomy of the region where these tumors occur. For this reason, a surgical approach to treating these tumors is technically demanding, and complete resection may be difficult to accomplish.A 71-year-old Japanese man presented at our hospital due to left anterior chest pain and an abnormal chest CT scan showing a 40 × 33 × 30-mm tumor located in the left anterior apex of the thoracic inlet. This tumor had invaded the first and second rib and was located near the subclavian vein. There was no significant distant metastasis. Therefore, we performed surgical resection. The surgical procedure included three steps. First, we performed VATS observation via the left thoracic cavity. Second, via the transmanubrial approach, we obtained tumor-free margins of the anterior cervical structures. Third, through VATS in the left lateral decubitus position, we performed left upper lobectomy and mediastinal lymph node dissection. This surgery was successful, with no postoperative complications.This surgical approach was effective and safe for treating a superior sulcus tumor located the anterior apex of the thoracic inlet. Next, VATS lobectomy is minimally invasive and safe after the transmanubrial approach for managing anterior superior sulcus tumor.We experienced a case of locally advanced superior sulcus tumor located at the anterior apex of the thoracic inlet and performed complete resection. The unique characteristics of superior sulcus tumors lie in the anatomy of region where these tumors occur. For this reason, a surgical approach to treating these tumors is technically demanding, and complete resection may be difficult to accomplish . The treWe experienced a case of a locally advanced superior sulcus tumor located at the anterior apex of the thoracic inlet and performed complete resection. This work has been reported in line with the SCARE criteria .2A 71-year-old Japanese man presented at our hospital due to left anterior chest pain and an abnormal chest computed tomography (CT) scan showing a 40 × 33 × 30-mm tumor located at the left anterior apex of the thoracic inlet. This tumor had invaded the first and second rib and was located near the subclavian vein . This paWe performed bronchoscopy to make a definitive diagnosis but were unable to obtain a diagnosis. 18-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography showed an increase standard uptake value in the tumor . There wThe surgical procedure included three steps. The diagram of the surgery and surgical view are shown in Pathologically, complete resection was achieved. The pathological diagnosis was stage IIB squamous cell carcinoma (p-T3N0M0). The patient was discharged from our hospital 13 days after surgery. This surgery was successful, with no postoperative complications.3Two points should be noted in association with this case. First, this surgical approach  was effective and safe for treating a superior sulcus tumor located at the anterior apex of the thoracic inlet. We first performed VATS via the left thoracic cavity. Rosso et al. reported that “VATS observation first” is useful for excluding previously undetected pleural dissemination and for precisely defining the tumor location . We therSecond, VATS lobectomy is minimally invasive and safe after the transmanubrial approach for managing anterior superior sulcus tumor. We performed left upper lobectomy and mediastinal lymph node dissection through VATS in the left lateral decubitus position after adopting the transmanubrial approach. Given the visual difficulty of performing lobectomy via the transmanubrial approach, it is necessary to change the position to the lateral decubitus position. However, thoracotomy is highly invasive. Therefore, VATS lobectomy is a good approach. As in the present case, VATS lobectomy can be performed if the tumor-invaded area of the anterior chest wall can be cut off via the transmanubrial approach. The present patient experienced little pain, and the postoperative course was good.4We experienced a case of locally advanced superior sulcus tumor located at the anterior apex of the thoracic inlet and performed complete resection.We have no sources of funding for our research.We got ethical approval from ethical committee of Kokura memorial hospital, Japan.We had informed consent from this patient for writing this paper.Soichi Oka; study design, writing. Kenji Ono; study design, other. Kenta Kajiyama; other. Katsuma Yoshimatsu; other.My research registry number is 1565.Soichi Oka and Kenji Ono.Not commissioned, externally peer-reviewed.We have no conflicts of interest.


Background and objectives: Abdominal wall endometriosis, also known as scar endometriosis, is a rare condition that is becoming increasingly common. The recent rise in incidence is attributed primarily to the surge of cesarean births, figures that could be influenced in a positive manner considering the improvements brought towards the ultrasound diagnostic methods that have been made in recent years. Materials and Methods: Here we report the cases of two Caucasian women of 38- (G2P2) and 36-years old (G1P1), both subjected to an ultrasound examination due to a specific symptomatic panel reported during anamnesis. Independently of the current status, in the first patient, there were no reported symptom-specific associations with endometriosis, but she had a known history of mild hereditary thrombophilia; the second woman suffered from two conditions positively associated with endometriosis. Results: In both cases, abnormal structures were revealed, with the diagnostic(s) of endometriosis being histologically confirmed based on a set of features observed during the investigation. Conclusions: This paper aims to highlight the importance of reducing cesarean births and to consider the diagnosis of scar endometriosis in women with a history of obstetric or gynaecological surgeries who present with cyclic, recurrent abdominal pain. Endometriosis is defined as the presence of functional ectopic uterine tissue glands and stroma outside of the uterine cavity . The aetIn most cases, endometriosis is located within the pelvis and mainly affects women of reproductive age. However, endometrial implants can be found outside the pelvis and can affect different organs, causing a variety of symptoms with a cyclical pattern of manifestation. The main sites targeted by extra pelvic endometriosis include the bowel, bladder, ureter, kidney, lymph nodes, lungs, and pleura, and also the abdominal wall .Scar endometriosis is a rare form of endometriosis that typically occurs after gynecological or obstetric procedures such as caesarean sections, various laparoscopic procedures that require uterine cavity manipulation, needle tract amniocenteses, or perineal episiotomies ,8,9.Regarding the pathogenesis of scar endometriosis, the most widely accepted hypothesis is that the endometrial cells are directly implanted via an iatrogenic process. Other theories have been proposed, such as lymphatic or hematogenous dissemination, metaplastic transformation, and cell immunity modification .Scar endometriosis is a challenging diagnosis to establish because it is reached rather by exclusion than as a positive diagnosis process. This is due to the non-specificity of symptoms such as cyclic abdominal pain, swelling, or bruising of the scar post-surgery. The ultrasound may be useful for preoperative diagnosis and evaluation of invasion into the subjacent anatomical planes. Preoperative evaluation of invasion is very important because, in case of large muscle invasion or deep invasion into the omentum or bowel, the participation of a general surgeon is necessary, with all the logistical implications .Herein, we present the cases of two patients suspected of suffering from abdominal wall scar endometriosis following caesarean births. Both patients were systematically evaluated preoperatively with 2D and Doppler ultrasound, the endometriosis being later on confirmed microscopically after surgical excision.A 38-year-old Caucasian woman with a history of two caesarean sections (G2P2), the last of which was in November 2015), presented to our outpatient department with complaints of a painful, palpable, small, firm mass of approximately 2 to 3 cm, located in the lower abdomen wall, at the site of the caesarean section scar, with no mobility to the deeper anatomical planes. The patient described her pain as relatively cyclic and timed the onset of the symptoms at 3 months after her last C-section. The patient was known to suffer from a mild form of hereditary thrombophilia, which required prophylaxis during her two pregnancies and had no other known endometriosis lesions elsewhere. The rest of the patient’s history was unremarkable: no natural births and no complications at the time of the two C-sections, no other relevant family history, no smoking or alcohol consumption, and no medications at the time of presenting.The ultrasound revealed an irregular, heterogeneous, hypoechoic, oblong solid mass with ill-defined margins, located within the subcutaneous fat, with some infiltration in the abdominal muscle but no mobility to the deeper anatomical planes .The excised specimen in both cases was microscopically described as the following: fragment of connective-muscle-fat tissue with glandular components and endometrial-like stroma, with intra- and extracellular hemosiderin deposits, lymphoplasmacytic infiltrate, and fibrosis. Therefore, the presumed diagnosis of parietal endometriosis was histologically confirmed .A 36-year-old Caucasian woman, G1P1 , presented complaining of cyclic pain on the C-section scar, as well as of moderate to severe dysmenorrhoea and dyspareunia, two symptoms well known to be associated with endometriosis. She also pointed to a painful, palpable, small firm mass of ~3 cm in the lower abdomen wall, at the site of the caesarean section scar .This patient had a history of ovarian endometrioma of ~6 cm removed by laparoscopy in 2014. Similar to the previous case, she was thrombophilic and had been administered Enoxaparin during pregnancy. Otherwise, her family history and her caesarean section were unremarkable, and there had been no natural births. She, too, was a non-smoker and a non-drinker and was not on any medication. Upon the endovaginal ultrasound examination of the posterior wall of the uterus, we found a nodular, 25/26 mm mass with imprecise margins, diffuse Doppler signal, intramyometrial varicose veins, sliding sign absent posteriorly and present anteriorly. The right ovary, sized 35 mm/24 mm/13 mm, was adherent to the posterolateral wall of the uterus and sensitive upon mobilization with the probe. The left ovary, sized 32 mm/16 mm/10 mm, was also adherent to the posterior wall of the uterus and the left uterosacral ligament, and there was a cystic mass measuring 13/14 mm, suggestive of ovarian endometrioma. There was no sign of free fluid in the Douglas pouch. Transabdominal ultrasound revealed a heterogeneous, hypoechoic solid mass with a polylobulated aspect and ill-defined margins, located in the subcutaneous fat near the C-section scar. The mass had some scattered internal echoes and absent Doppler signal. Surgical excision was difficult due to invasion and lack of cleavage plans. The nodule section revealed a typical aspect , and theScar endometriosis is an entirely iatrogenic disease with an incidence of 0.03–1% in women with a history of caesarean births . It can The diagnosis is usually delayed because the signs and symptoms are not specific, and cyclic abdominal pain is not a pathognomonic sign for scar endometriosis. The differential diagnosis should be made with granuloma, desmoid tumor, lipoma, abscesses, sebaceous cysts, ventral hernias, or metastasis . In our In addition to the anamnesis and clinical examination, the ultrasound should be the first-line imagistic method for diagnosis. High-frequency linear transducers are best for such assessment .Upon ultrasound, a round or oval lesion with imprecise borders can be found at the site of the scar. The lesion typically appears as a hypoechoic area surrounded by a hyperechoic ring, with low or even absent blood flow when viewed in Doppler mode.The treatment of scar endometriosis consists of wide lesion excision with a minimum 1 cm safe margin in order to avoid recurrence. In cases of incomplete excision of the lesion, the risk of recurrence varies between 12.5–28.6% . In our Scar endometriosis is, unfortunately, a disease with increasing incidence due to the rising rate of births by caesarean section and delays in diagnosis leading to abdominal wall invasion and serious health risks for the patient. It is very important to consider such a diagnosis in all patients of reproductive age who present with painful masses at the level of their scars. Among the various complications, delayed diagnosis can cause the patient to have to undergo complex and invasive surgical procedures, which may significantly impact their quality of life. The ultrasound is an accessible imagistic method and should be used routinely to evaluate any scar-related masses. Once a first nodule is detected, the entire scar must be assessed, and an ultrasound evaluation for ovarian endometriosis and deep endometriosis should be performed . In what concerns the management strategies, this topic remains controversial. Because of the relatively low incidence of abdominal wall endometriosis, there is a relatively small body of evidence in the current literature. There are situations when surgery can be avoided, especially in cases of endometriomas or recurrent endometriomas that can be medically managed. Surgical intervention becomes imperative for patients that report perpetual pain, structures that are possibly malignant, infertility, or gradual increases in size.Discrepancies regarding the usage of oral medication have been noted. They improve the overall health condition, but the success rate is low, and the recurrence chances once the treatment is ceased are high . In contAmong all the above mentioned, GnRH is also are widely used and dedicated to reducing pain and slowing the progression of endometriosis. In this way, GnRH’s pharmacokinetics led to conflicting results. While some authors argue that GnRH has no beneficial effect ,18, we iThe role of danazol has been recently explored from various perspectives. To make a parallel and considering that it is well absorbed, this synthetic steroid causes gastrointestinal deficiencies in patients and a clinical panel identical to that observed in SARS-CoV-2-infected patients. Specific phenotypes that reflect metabolic and psychiatric disturbances have also been documented quite frequently. In this context, the limited number of studies carried out is explained, many of which were carried out before 2000 .Through the prism of all data available, dienogest is a novel adjuvant to surgery and possesses an effective and tolerable compound that enjoyed a sudden emergence in recent years. Retrospectively, Bedaiwy et al.  summarizTo deepen this discussion, it seems that oral contraceptives were successfully used to lower the prevalence of endometrioma at the initial laparoscopy . Having Moreover, the risk is up to four times diminished following cystectomy, and women are prescribed twenty-four to seventy-two weeks of combined oral contraceptives (COCs) versus no treatment . AdditioCumulatively, COCs are the most eligible alternative for reducing large endometriomas , with noWe identified only one study in which endometriosis was treated with ultrasound-guided ethanol injection. Bozkurt et al.  applied On the other hand, surgery remains the method of choice for clinicians since it offers two viable options; treatment and definitive diagnosis. It is crucial to first remove the nodule(s) and the adjacent fascia thoroughly. Unfortunately, the risk of novel lesions or reoccurrence of abdominal wall endometriosis is relative . Some reSclerotherapy by ethanol injection before surgical resection represents another option, but intralesional ethanol injection may result in difficult-to-repair necrosis on the anterior muscles of the abdominal wall in large lesions. In endometriosis foci extending into the intraperitoneal region, it may also cause complications including chemical peritonitis and severe pain as a result of alcohol penetration into the peritoneum. In such patients, therefore, injections may be given in several sessions instead of a single session. Compared with the complications of surgical excision, the complications of sclerotherapy by ethanol are at a more acceptable level. Along with ethanol sclerotherapy, plasma energy is also attributed to such interventions, being less invasive, and optimal for women desiring to conceive .Distinct surgical approaches may include polypropylene-mesh-closing, reserved for the cases with massive wall defect due to the invasion of the aponeurosis, a technique meant to lessen tissue tension. In wide surgical resections, complications including foreign substance reactions, mesh migration, and eventual incidence of hernia may appear due to the propylene mesh used. In the literature, abdominoplasty with polypropylene mesh is recommended for abdominal wall reconstruction in large lesions to reduce hernia development .Although ultrasound is the most cost-efficient method of imaging evaluation, it is highly recommended and preferable that, in the case of abdominal wall endometriosis, further more detailed imaging investigations be conducted, such as CT/MRI. Such exams can offer important aspects regarding those lesions such as the extent of the tissue involvement and the state of all of the structures that come in close contact with the lesion.There has been recent discussion about the usefulness of CT in the diagnosis of endometriosis. CT does not visualize pelvic organs but rather can be used to detect ureteral involvement and/or renal insufficiency .However, the experience of the radiologist is essential considering that the average acquisition time for both high- and low-resolution MRI was twenty-four minutes. The values of specificity, sensitivity, and positive and negative predictive values (NPV/PPV) did not differ significantly, which is why both are considered valuable tools for detecting deep endometriosis extension . Bermot n = 25). Whereas major changes were made in 8.1% (n = 11), minor changes were necessary in 13.2% (n = 18) of patients. Yap et al. [n = 37). With 195 days average time interval, middle compartment sensitivity (79.4%/specificity of 95.1%), posterior compartment sensitivity (76.5%/specificity of 99.4%) and the overall sensitivity and specificity of detecting bowel endometriosis of 94.4%, and 94.7% respectively, system benchmark diagnostic performance can be achieved through 3 T MRI.One good example is represented by the study of Burkett et al. , in whicp et al.  combinedn = 76 out of 83). In the present case, the sensitivity, specificity, NPV and PPV were 83.3%, 98.6%, 90.9% and 97.2%, respectively. Despite these data, it was recently demonstrated that laparoscopy is superior to MRI (p < 0.0001) especially in diagnosis chronic pelvic pain, but the MRI agreement with histopathology or laparoscopy was poor (p < 0.0455). The second diagnostic criterion was significantly improved in 96.9% of the cases (p < 0.0000) [Another retrospective study conducted by Bazot et al. , in whic 0.0000) .To date, no evidence leans towards or against the suture of the peritoneum concerning the incidence of AWE, nor is the change of gloves during the surgery recommended when completing the hysterorrhaphy. For abdominal wall endometriosis, total surgical excision is considered to be the gold standard for both diagnosis and treatment .Although there is numerous evidence that the technique for uterine closure can be crucial for uterine scar healing, strong evidence regarding optimal techniques is little and there currently exist no national or international guidelines that obstetricians and gynecologists can rely on. Most randomized trials that have evaluated the uterine closure technique during caesarean have focused on the short-term operative complications without evaluating the impact on future pregnancies or the risk of developing caesarean scar endometriosis. Since there is no consensus on the matter, it is up to the surgeon and his clinical experience to adapt the techniques given the intraoperative findings .The gold standard treatment in such cases is surgical, consisting of the excision of the mass within safe margins. This also allows for the specimen to be histopathologically analyzed to confirm the diagnosis. Moreover, an interesting approach would be finding an explanation regarding why some women are more susceptible to developing this condition while others are not and thereby determining if there are other factors involved such as genetics and environmental ones.


A 55-year-old woman with a history of end-stage renal disease, peripheral vascular disease, and multiple prior abdominal surgeries presented to the emergency department with three days of diffuse, severe, abdominal pain with accompanying nausea, emesis, and food intolerance. A computed tomography (CT) of her abdomen demonstrated a “whirl” of small bowel and mesenteric vessels, raising suspicion for mesenteric volvulus and resultant small bowel obstruction.Mesenteric volvulus is a low incidence, high mortality condition; therefore, early recognition and operative intervention are critical. Patients with a “whirl sign” on CT are more likely to require surgical intervention for their small bowel obstruction. A 55-year-old woman with a history of end-stage renal disease, peripheral vascular disease, and multiple prior abdominal surgeries presented to the emergency department with three days of diffuse, severe, abdominal pain with accompanying nausea, emesis, and food intolerance. Her physical examination was remarkable for a soft, slightly distended abdomen with diffuse tenderness to palpation. She had no guarding or rebound. A computed tomography (CT) of her abdomen demonstrated a “whirl” of small bowel and mesenteric vessels , raising2In this patient, an exploratory laparotomy was performed amid concern for small bowel ischemia, and a mesenteric volvulus was confirmed intraoperatively. A small bowel resection with extensive adhesiolysis was performed, and multiple mesenteric lymph nodes were excised. The patient had an unremarkable postoperative course and was discharged home.Mesenteric volvuli occur when bowel twists around its mesenteric root.4What do we already know about this clinical entity?Mesenteric volvulus occurs when bowels twists around its mesenteric root and can result in bowel wall and vascular compression, intestinal obstruction and ischemia.What is the major impact of the image(s)?Mesenteric volvulus is a low incidence, high mortality condition. Therefore, early recognition and operative intervention are critical.How might this improve emergency medicine practice?Whirl sign is helpful for guiding management of patients with signs of small bowel obstruction, as patients with this finding are more likely to require surgery.VideoMesenteric whirl sign. Computed tomography of the abdomen demonstrates a swirling mass (see arrow) of soft-tissue and fat attenuation indicative of twisted loops of small bowel and mesenteric vessels.


Basidiobolomycosis is an infrequent fungal infection. It is largely a subcutaneous infection and its gastrointestinal involvement is an uncommon phenomenon. Herein, we report the case of gastrointestinal basidiobolomycosis in a 45-year-old Saudi woman who presented to the clinic with a three-week history of abdominal pain. Although infrequent, however, gastrointestinal basidiobolomycosis should be contemplated in patients presenting with abdominal pain, hematologic eosinophilia, and inflammatory gastrointestinal mass. Basidiobolus ranarum, a saprophytic fungus that is affiliated with the Zygomycetes family [Basidiobolomycosis is an infrequent fungal infection . It is ms family . Skin ans family ,3. Nonets family ,5. It iss family ,4,5. Thes family ,4,5. HerA 45-year-old Saudi woman presented to the emergency department complaining of abdominal pain for five days. The pain was diffuse, aching, eight of ten for severity, and non-radiating. It was associated with nausea, vomiting, and constipation, but no blood in the stool. Past medical history was remarkable for diabetes mellitus and hypertension. Past surgical history was notable for appendectomy nine years ago.On physical examination, vital signs were remarkable for fever of 37.9°C  and increased respiratory rate of 24 breaths/min . Abdominal examination revealed diffuse tenderness, mostly involving the right side. No palpable masses were detected. Bowel sounds were normal. A digital examination was not performed.9/L  with a high eosinophil count of 290 x 103 cells/uL . Additionally, the patient had an elevated erythrocyte sedimentation rate of 112 mm/h . Tumor markers, including carcinoembryonic antigen (CEA) and cancer antigen 125 (CA-125), were within normal limits.Initial Blood tests revealed an elevated white blood cell count of 14.9 x 10The patient underwent an abdominal x-ray which showed multiple air-fluid levels Figure . ContrasB. ranarum pathogen.In view of potential small bowel obstruction and a malignant mass, the patient underwent exploratory laparotomy. The right-sided mesenteric mass was identified and resected. Hematoxylin and eosin staining revealed fungal hyphae within necrotizing granuloma and surrounded by intense eosinophilic material, most likely representing the Splendore-Hoeppli phenomenon Figure . PeriodiThe patient had an uneventful postoperative course. The patient received itraconazole therapy. At six weeks follow-up, the patient was symptom-free. The plan was to continue therapy for additional 12 weeks and assess the patient again in the clinic with the radiographic examination. Basidiobolomycosis is a rare fungal infection . It is lB. ranarum transmission is not certainly defined. Nonetheless, with regard to subcutaneous disease, it is most likely contracted following an insect bite or minor skin trauma. Conversely, with regard to gastrointestinal disease, it is most likely contracted secondary to ingestion of objects polluted by B. ranarum, such as foodstuff, animal feces, and outdoor soil. The latter mechanism appropriately rationalizes the high proportion of gastrointestinal basidiobolomycosis cases, particularly among children [The precise mechanism of children ,7. With regard to blood tests, elevated erythrocyte sedimentation rate, eosinophilia, and neutrophilic leukocytosis are frequent laboratory findings recognized in patients with gastrointestinal basidiobolomycosis ,5,6. AllAnatomically, gastrointestinal basidiobolomycosis most frequently targets the colon. Signs and symptoms of gastrointestinal basidiobolomycosis are largely non-specific during clinical presentation . Indeed,Various radiographic modalities are utilized to characterize gastrointestinal basidiobolomycosis. Such radiographic modalities commonly abdominal x-ray, computed tomography, and upper gastrointestinal series. The most frequently recorded findings comprise abdominal masses of the colon, with an inflammatory reaction, bowel wall thickening, and abscess formation . DiffereB. ranarum is attained in 50% to 65% of the cases [Diagnosis is difficult to be made preoperatively. Several case reports employed preoperative diagnostic procedures, such as endoscopy and biopsy, however, they largely failed to establish the diagnosis . Similarhe cases .Pathologic examination of the resected gastrointestinal mass establishes the definitive diagnosis. Distinctively, gastrointestinal basidiobolomycosis is manifested by the occurrence of Splendore-Hoeppli bodies, enrichment of eosinophils, and presence of abundantly radiating eosinophilic granular materials .B. ranarum often exhibits resistance to amphotericin B in close to 50% of the cases [Surgical excision plus antifungal therapy represents the standard of care in the management of gastrointestinal basidiobolomycosis ,5,6. Thihe cases .The prompt diagnosis followed by treatment is key to guarantee a favorable prognosis. This is because delayed management can culminate in disseminated disease with serious consequences, such as mortality up to 16-20% of cases if left untreated . AdditioGastrointestinal basidiobolomycosis is an uncommon fungal infection. Its diagnosis is challenging owing to the natural rare incidence and presence of non-specific symptomatology that may mimic other common conditions. Pathologic examination findings are distinctive and can establish the definitive diagnosis, in conjunction with the relevant clinical history and blood test results. Prompt management with surgery and antifungal therapy is key to mitigate morbidity and mortality. Lastly, although infrequent, however, gastrointestinal basidiobolomycosis should be contemplated in patients presenting with abdominal pain, hematologic eosinophilia, and inflammatory gastrointestinal mass.


Introduction: Persistent Müllerian duct syndrome (PMDS), or uterus masculinus, is a rare autosomal recessive form of male pseudohermaphroditism due to the failure of paracrine anti-Müllerian hormone (AMH) secretion by Sertoli cells or failure of the Müllerian ducts to respond to AMH secretion. The malignant degeneration of persistent Müllerian remnants is rare. In human medicine, few related reports exist. In veterinary medicine, this is the first report describing adenocarcinoma of the uterus masculinus involving the prostate in a dog.Clinical history: An 11-year-old, male, neutered Pomeranian dog was referred for computed tomography due to the suspicion of prostatic carcinoma based on ultrasound and cytological examinations. The computed tomography findings were consistent with a uterus masculinus mass with possible prostatic infiltration. Uterus masculinus removal and total prostatectomy were performed; termino-terminal urethral anastomosis was carried out. Dehiscence of the anastomosis was observed 3 days after surgery. The owner declined any further procedures, and the dog was euthanized 5 days after surgery. Histopathological evaluation revealed adenocarcinoma of the uterus masculinus.Conclusion: Adenocarcinoma of the uterus masculinus may occur, suggesting that patients with PMDS should be evaluated for malignant changes of Müllerian remnants. Persistent Müllerian duct syndrome (PMDS), or uterus masculinus, is a rare condition in both male humans and dogs, in which the embryological remnant of the Müllerian duct system has not regressed , 2.The Müllerian duct system is present in both male and female mammalian embryos , 4. In nMüllerian inhibiting substance (MIS) also called anti-Mullerian hormona (AMH) is secreted by Sertoli cells and is responsible for regression of Mullerian ducts during embryonic development in male mammals. However, Mullerian structures  could be present in dogs with Müllerian duct syndrome (PMDS) .In canine PMDS, the affected dog appears masculine in all outward appearances, but can retain their Müllerian structures. However, PMDS should be suspected in cryptorchid males, mainly in miniature Schnauzers .MDS is known to be an inherited autosomal recessive disorder in miniature Schnauzers . It has PMDS or uterus masculinus is a rare condition in dogs. Sometimes it is a coincidental finding during abdominal diagnostic imaging or surgery. However, it may also be detected because of associated disorders, such as urinary tract infection, pyometra, hydrometra, cystic uterus, prostatitis, cryptorchidism or testicular neoplasia . RecentlA primary tumor involving the Müllerian duct remnants has never been reported in veterinary literature.Thus, the aim of this report was to describe a unique case of adenocarcinoma of uterus masculinus in a Pomeranian dog.An eleven-year-old, neutered, male Pomeranian dog with a body weight of 2.7 kg was referred for computed tomography (CT) due to the suspicion of prostatic carcinoma after the ultrasound (US)-guided cytological examination performed by the referring veterinary surgeon. On anamnesis, the dog was neutered at 1 year of age. The owner reported observing frequent and difficult urination and blood in the urine over the last 2 months. Clinically, the dog presented with pain on digital rectal prostatic examination and an irregular dorsal prostate surface.Biochemistry and hematology analyses did not show any relevant features. Urinalysis showed an erythrocyte level of 250/μl (> 50 HPF), a leucocyte level of 100/μl (> 50 HPF), and an epithelial non-squamous cell level of 3–5/HPF. The urine culture result was negative.Pre and post intravenous contrast medium administration whole body CT showed a heterogeneous attenuation prostate gland measuring 2,4 mm in diameter with focal mineralization in the left lobe .Dorsal to the prostate, an irregular tubular structure with no cleavage plane with the prostate was present. It continued cranially, ending with two asymmetrical horns.The dog underwent surgery 2 weeks later. No medication was administered in the interim. Before surgery, US was performed and showed that the body of the uterus masculinus and the left horn were heterogeneous, while the right horn was mainly hypoechoic. All structures showed wavy but well-defined borders. The maximum thickness of the uterus masculinus was 16 mm in the body, 13 mm in the right horn, and 10 mm in the left horn. The total length was approximately 22 mm for the body, 30 mm for the right horn, and 14 mm for the left horn.The dog was sedated with morphine  and acepromazine  20 min before induction. After 5 min of preoxygenation, anesthesia was induced with propofol . Cefazoline  was administered at induction. The patient was then intubated with a cuffed endotracheal tube, and a stable level of anesthesia was achieved with sevoflurane and oxygen with the patient positioned in dorsal recumbency.A midline celiotomy from the xiphoid process to the pubic bone was performed. Surgical exploration of the caudal abdomen revealed the presence of a uterus with two small horns and evidence of prostatomegaly. The uterine body with the two cranially oriented horns was located and attached dorsally to the prostate.The surgical procedure aimed to remove the mass involving the uterus masculinus in association with total prostatectomy.To increase exposure of the urethra, bilateral pubic and ischial osteotomy was carried out. The division between the right and left adductor muscles was incised sharply, taking care to stay exactly on the midline to minimize hemorrhage. The adductor muscles were then elevated subperiosteally from the pubis and ischium with a one-fourth inch Keys periosteal elevator. Elevation was continued until the obturator nerves and approximately two-thirds of the obturator foramina were visible. The prepubic tendon was incised along the pubis to the level of the proposed pubic osteotomy sites. A 2 mm pin chuck was used to drill 2 holes on either side of the 4 proposed osteotomy sites. The right and left pubis and ischium were then osteotomized with a sagittal oscillating saw. The internal obturator nerves were protected with a malleable retractor while osteotomy was performed. The internal obturator muscle was elevated subperiosteally from the right pubis and ischium, allowing resection of the central bony plate to the left, and the idiopathic prostatic gland was identified through palpation. The urethral sagittal incision was then performed caudal to the prostate. Stay sutures were placed to prevent rotation of the urethral stump, a Foley catheter was advanced across the defect into the bladder, and the retaining balloon was inflated. End-to-end anastomosis with simple interrupted sutures using a 4-0 monofilament absorbable suture material was performed. The bony plate was reduced, 2-0 polydioxanone sutures were placed through the previously drilled holes at each osteotomy site and secured. The adductor muscles were reapposed with 3-0 polydioxanone sutures in a cruciate pattern. The prepubic tendon was secured to the pubis with 3-0 polydioxanone sutures in a simple interrupted pattern. The linea alba was closed with 3-0 polydioxanone sutures in a simple continuous pattern, and subcutaneous tissues and skin were closed routinely.On gross inspection, the excised mass clearly resembled a uterus, consisting of a main central body and two asymmetrical “horns.” The mass was quite firm on palpation; on cross-sectional observation, it appeared homogeneously whitish-gray, with no lumen evident .Postoperative managementThe entire excised mass was fixed in 10% buffered formalin; then, representative samples were collected from the body and both horns, embedded in paraffin and routinely processed for histopathological (hematoxylin and eosin staining) and immunohistochemical investigations. The dog recovered under close supervision in the intensive care unit. Postoperative medication included methadone , intravenous cefazolin , and continuous intravenous 0.9% NaCl crystalloid therapy. Postoperative complications were classified as major in the event of surgical revision and as minor in the case revisional surgery was not required.Three days later, dehiscence at the urethral sutures with abdominal effusion was observed as a complication. Surgical revision was suggested, but worsening of the patient's condition led the owner to choose euthanasia.Microscopically, epithelial neoplastic proliferation was observed, diffusely infiltrating the entire mass. Neoplastic cells were large and polygonal-shaped, with a single nucleus and abundant cytoplasm. Nucleoli were prominent, and mitotic figures were also commonly observed (0-2/HPF). The arrangement of neoplastic cells varied throughout the mass, from solid to cystic-papillary in appearance . Large aBased on the histopathological findings, the diagnosis of persistent Müllerian duct adenocarcinoma was made.In humans, uterus masculinus has been defined as the persistence and subsequent formation of female genital organs  in normal males . AdenocaIn 2002, Shinmuta et al.  reportedIn the veterinary medicine literature, a primary tumor of the uterus masculinus has never been reported , 11–16.In 1986, Atilola et al.  describeIn 2009, Matsuu et al.  reportedThe management of PMDS may be conservative , 8. In cIn the present report, we presented a unique case of adenocarcinoma of the uterus masculinus involving the prostate in a neutered Pomeranian dog. The patient was referred with a diagnosis of suspected prostatic adenocarcinoma obtained by fine-needle aspiration (FNA) performed under US guidance. Tumor staging achieved by CT allowed us to exclude any metastatic lesions and to observe the presence of a mass dorsocranially to the prostate consistent with uterus masculinus.Enhanced CT of the pelvis showed a heterogeneous enhancement of the prostatic gland and dorsocranial to the prostate a well-defined, tubular, with thick wall structure consistent with the uterus that showed peripheral contrast enhancement and extending to the right inguinal area. In reconstruction images both uterine horns were evident. The above CT findings were of paramount importance in the diagnosis, leading to the uterus masculinus mass.CT is an excellent imaging modality for evaluating the abdomen and unlike US is not limited by intestinal gas. Moreover, it can be used to confirm ultrasonographic findings and allows a more thorough presurgical evaluation of the abnormal anatomy . In humaComplications associated with total prostatectomy include urethra incisional dehiscence, urinary incontinence, hemorrhage and uroabdomen . Due to The main limitation of this study is related to the lack of information regarding the history of the dog during the first year of life. In particular, as the dog was neutered at 1 year of age, we were not able to detect any further pathology that may be associated with PMDS.In conclusion, adenocarcinoma of the uterus masculinus may occur, suggesting that patients with PMDS should to be evaluated for malignant changes of Müllerian remnants.All datasets presented in this study are included in the article/supplementary files.Ethical review and approval was not required for the animal study because the study was a case report, thus no ethical approval was required. Written informed consent was obtained from the owners for the participation of their animals in this study. Written informed consent was not obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.MV, ID, RTa, GQ, and GM wrote the paper. MV, RTe, NS, and SP were involved in the Imaging assessment. FC, RTa, and MV performed the surgical procedure. GM was in charge for the histopathological evaluation. MV was responsible for the final content. All of the authors have read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Takayasu arteritis (TA) is a rare inflammatory arteritis that is usually affecting young women and causes ischemic changes in the vessel wall. In this report of TA leading to an acute ischemic stroke, we describe a treatment-resistant case, with short interval flares and the challenge of defining the stroke etiology as a large vessel occlusive disease vs. an arteritis flare. We have used CT and MRI modalities to show the active disease and got diagnostic answers from this tool.  Takayasu arteritis (TA) is a rare large vessel inflammatory arteritis that is usually affecting young women and causes ischemic changes in the vessel wall. It presents with complications of vessel lumen narrowing, such as ischemic pain, claudication, painful carotid, differences in systolic blood pressure (SBP) between arms, decreased brachial artery pulse, bruit over involved arteries, and stroke . Signs aA 25-year-old Caucasian woman with a history of TA admitted to our hospital with headache, agitation, and aphasia. She could not comprehend questions and write or repeat words. The patient was out of the window for tissue plasminogen activator (tPA) administration. The patient was diagnosed with TA at age 14 years. She had been on sarilumab and prednisone for four months before the presentation, and she was compliant with the treatment. Initial CT of the head did not reveal any acute abnormalities. CT angiography of the head and neck revealed occlusion of the M2 branch of the left middle cerebral artery Figure  but pateGiven that the M2 thrombus was distal, the patient was not a candidate for mechanical endovascular treatment. MRI of the brain was remarkable for restricted diffusion within the gyri of the left temporoparietal lobes Figure . Her iniAt the end of the steroid treatment, the patient had an MRI brain of the head and neck with contrast, which showed active contrast enhancement on the wall of the left distal common carotid artery Figure , right, Stroke is not rare 15.8%) and is a significant disability factor in the TA patient population 5.8% and . If the Different non-invasive methods have been used to differentiate between acute disease processes and intra-arterial disease-related damage . Ultrasonography (US), MRI, MR angiography, CT angiography (CTA), and positron emission tomography (PET) have been studied in patients with TA . CurrentDiagnosing the stroke etiology in TA patients, especially to identify whether the vessel wall pathology is an acute or chronic process causing an acute ischemic stroke, is an essential but challenging step. MRI T1 with fat suppression of the head/neck could be utilized to assess vessel caliber, patency, and for detection of inflammation within the vasculature, specifically in the vessel wall.


Ancient schwannoma is an extremely rare benign, peripheral nerve sheath tumor. Despite its benign nature, its characteristic heterogeneous appearance and degenerative changes commonly lead to misdiagnosis of malignancy. Although schwannomas are extremely uncommon in the pediatric population, these neoplasms have been associated with underlying conditions such as neurofibromatosis type two, and appropriate recognition is important to ensure close monitoring of potential future symptoms secondary to other tumors. We report the imaging and laboratory findings of an ancient schwannoma of the vagus nerve in a 10-year-old female, the first documented case of such a tumor in a pediatric patient, and discuss its characteristic findings and diagnostic considerations. Awareness of this rare tumor can help promote correct diagnosis and avoidance of costly, high-risk diagnostic methods. Schwannomas are benign, neurogenic tumors originating from Schwann cells surrounding peripheral nerves. These rare lesions can arise from peripheral nerves surrounded by Schwann cells in any area of the body. They are most often found in the head, neck, and extremities -3. The vSchwannomas are divided into different subtypes based on their histologic characteristics. Ancient schwannoma is an uncommon subtype of these rare neoplasms, histologically characterized by degenerative changes and diffuse hypocellular patterning, which often leads to misdiagnosed malignancy despite the tumor’s benign nature ,5. ThereA 10-year-old female presented to her primary care provider with a three-day history of sore throat and cervical lymphadenopathy. The sore throat improved after four days of antibiotic therapy, but persistent right cervical lymphadenopathy warranted follow-up at her primary care clinic. Aside from periodic low-grade contralateral posterior neck pain and intermittent difficulty in swallowing, the patient was asymptomatic. White blood cell count, mononucleosis spot test, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were unremarkable, and Epstein-Barr virus (EBV) studies were consistent with prior infection. A right neck ultrasound (US) revealed a solid hypervascular mass deep to the right sternocleidomastoid muscle (SCM) and posterior to the carotid artery and internal jugular vein, as seen in Figure Outside imaging was reviewed and, after unremarkable CRP, complete blood count, and urine and blood metanephrine studies performed at our institution, magnetic resonance imaging/angiography (MRI/MRA) was obtained. This identified a well-defined 3.0 x 2.3 x 4.1 cm ovoid-appearing, heterogeneous mass seen within the right carotid space. On postcontrast sequences, there was avid enhancement with internal areas demonstrating less prominent enhancement and no restricted diffusion. The mass displaced the right internal jugular vein anterolaterally and the internal carotid artery anteromedially with associated prominent and mildly enlarged cervical lymph nodes felt to be reactive in nature  performed for this patient are illustrative of the imaging characteristics of ancient schwannomas and makes this case unique in comparison to its counterparts which classically include only one or two imaging modalities. US in Figure Although imaging can assist in the diagnosis of ancient schwannoma, histopathology is the only method of confirmation. In this case, diagnosis of schwannoma was made via ultrasound guided FNA and ancient subtype was confirmed post-excision. FNA was chosen to aid in diagnosis, triage urgency of surgical excision, and could be performed with local anesthetic only. The use of FNA in schwannoma diagnosis remains controversial due to challenges in representative specimen acquisition and difficulties in making a confident diagnosis based on a limited sample ,8. DespiNeurogenic tumors make up only 2% of benign, pediatric neoplasms but they are commonly associated with underlying conditions such as neurofibromatosis types one and two  ,6. SchwaDespite the rarity of schwannomas in the pediatric population, clinicians should be aware of their presence due to the association with underlying genetic conditions and symptoms related to those conditions. FNA should be strongly considered to aid in diagnosis and accurate surgical planning and can be performed safely with minimal to no sedation. Understanding the histologic and radiologic characteristics of the ancient schwannoma subtype can help avoid misdiagnosis of malignancy and improve efficiency and accuracy of care.


Benign tumors of the esophagus are rare. However, among them, leiomyomas are common. Tumors larger than 5 cm are rare and may present as dysphagia or epigastric pain. Combined esophagoscopy and video-assisted thoracoscopic surgery or laparoscopic trans hiatal resection are used the management of leiomyoma of esophagus.This case report illustrates the case of a young male who presented with dysphagia and occasional dyspnea. Imageology demonstrated an esophageal mass which on surgical exploration and histopathology, confirmed the diagnosis of leiomyoma.Esophageal leiomyomas vary in their presenting size from a few centimeters to greater than 5 cm which are rare. The preferred surgical technique for leiomyomas is transthoracic enucleation without opening the mucosa, which is easier, faster, and safer compared to resection. In our patient, due to the size and location of the tumor, it was resected using an abdominal approach, and a distal esophagectomy and esophagogastrostomy were performed.A multi-modal approach involving both the endoscopic and radiologic examinations is crucial in ensuring that the morbidity of malignancy is avoided. The lar2A 28-year-old male patient presented with a complaint of dyspepsia and esophageal reflux. A history of Nausea, vomiting, and weight loss were absent with no abnormality detected on physical examination and laboratory tests. Roentgenography of the chest revealed a mass with a filling defect in the right hemothorax Computerized tomography (CT) of the chest and abdomen showed a well-defined lobulated soft tissue mass (7 × 3.5 × 5.5 cm) on the posterior wall of the distal esophagus, gastroesophageal junction and adjoining portion of the posterior wall of the gastric fundus .Fig. 1Histopathology revealed the mass to be composed of neoplastic spindles cells arranged in bundles and fascicles. The cells had oval to elongated nuclei and a moderate amount of pale to eosinophilic cytoplasm, with mitotic figures less than 2 per 10 high power field and no evidence of necrosis . A negat3Leiomyoma often have an intramural location but some present near the esophageal diverticula or grow intramurally as a pedunculated polyp. Preoperative diagnosis of esophageal leiomyoma is often challenging as it can present as a posterior mediastinal mass on chest radiograph and may be seen as an incidental radiological finding . Barium The surgical indications of these tumors include unremitting symptoms, increased tumor size, mucosal ulceration, histopathologic diagnosis and facilitation of other surgical procedures . Maligna4The diagnosis of esophageal leiomyoma requires both endoscopic and radiologic examinations. Larger esophageal leiomyomas can be successfully resected using esophagectomy and esophagogastrostomy by abdominal approach. Stapler anastomosis can provide long survival and better quality of life. A multi-modal approach to ascertain diagnosis is crucial in ensuring that the morbidity of malignancy is avoided.Nil.Nil.Ethical approval has been exempted by our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Case report concept and design was contributed by Dr. Sheetal A Murchite. Case report analysis was done by Dr. Rajendra M Kulkarni.Data collection and case report writing was done by- Dr. Thakut Gowtham and Dr. Vaishali V Gaikwad.1.Name of the registry: NA.2.Unique identifying number or registration ID: NA.3.Hyperlink to your specific registration (must be publicly accessible and will be checked): NA.Dr. Thakut Gowtham.Dr. Sheetal A Murchite.Dr. Vaishali V Gaikwad.Not commissioned, externally peer-reviewed.


Dedifferentiated liposarcoma, one of the most deadly types of soft tissue sarcoma, is an aggressive and high-grade form of liposarcoma. Liposarcoma occurs most commonly in the retroperitoneum, extremities and trunk, but less frequently in the female genital tract. The vagina is a very rare site of origin. Herein we report the first case of dedifferentiated Liposarcoma deriving from vagina and discuss its clinical course.A 38-year-old female patient presented to our institution with a painless vaginal mass. Abdominal computed tomography showed a 17.6 cm× 10.4 cm solid mass originating from the right lateral wall of her vagina. Then she underwent complete surgical resection of the tumor mass, and postoperative pathological result confirmed the diagnosis of dedifferentiated liposarcoma deriving from vagina. Six courses of combination chemotherapy with pirarubicin plus ifosfamide were performed after surgery. The patient remains with no evidence of disease recurrence with 13 months of follow-up.Liposarcoma is very rare in female genital tract, and more rare for dedifferentiated liposarcoma in gynecologic field. Little is known about the clinical characteristics, pathological diagnosis, prognosis and optimal management strategy of vaginal dedifferentiated liposarcoma. Complete surgical resection followed by systemic chemotherapy is suggested to be standard treatment for dedifferentiated liposarcoma. Combination chemotherapy with pirarubicin and ifosfamide may be effective for treating vaginal dedifferentiated liposarcoma. Liposarcoma (LPS) was firstly designated by Virchow in 1857 . The 202Liposarcoma is very rare in female genital tract, but relatively common in male genitourinary system especially around the testis and spermatic cord. There have been very few reports of liposarcoma either in uterine corpus or in adnexal region –8. To thA 38-year-old female patient, gravid 3 para 2 abortion 1 was referred to our hospital with a one-year history of vaginal mass. One year before admission, the patient felt vaginal uncomfortable and found a mass in her vagina. The patient, lived in a remote rural area, did not go to the hospital for further examination due to her poor economic condition. She experienced discomfort in the vagina and felt the vaginal mass was growing progressively in the past year before admission. Her general medical history revealed no surgery and disease. At the time of consultation, vaginal examination demonstrated a large fixed mass was located in the right lateral wall of the vagina and occupied the upper and middle third of the vagina. Laboratory blood test results, including serum tumor markers, were all within the normal ranges. Abdominal computed tomography (CT) showed a 17.6 cm× 10.4 cm solid mass in pelvic cavity  were performed for the patient. The patient remains well with no evidence of disease recurrence with 13 months of follow-up. We are still following-up this patient.The patient was discharged 7 days after surgery without any immediate postoperative complications. Medical oncology was consulted, and additional chemotherapy were recommended. Six courses of combination chemotherapy with a regimen of pirarubicin plus ifosfamide (pirarubicin 30 mg/mDedifferentiated liposarcoma (DDLPS), one of the most deadly types of soft tissue sarcoma, is an aggressive and high-grade form of liposarcoma (LPS) . DDLPS iDDLPS usually present as slow-growing and painless masses. DDLPS have no specific clinical symptoms, and they are commonly found incidentally. The clinical manifestations usually depend on where the DDLPS occurs. For example, DDLPS occurs in abdominal retroperitoneum may present with symptoms of abdominal pain or distension. DDLPS occurs in vagina may present with vaginal discomfort or pain, like the patient in this study.Correct diagnosis is extremely difficult before surgical resection. The diagnosis of DDLPS depend entirely on postoperative pathology, but it is reported that a significant percentage of patients with DDLPS had an initial pathological misdiagnosis. Incorrect diagnosis could result in delayed or inadequate treatment. In our case, the patient was initially suspected to have anaplastic vaginal carcinoma because of the rapid extension of the tumor.Grossly, DDLPS usually present with a large (> 10 cm) and multinodular mass , which vSurgery is still the main modality in the treatment of localized DDLPS . MacroscAlthough complete surgical resection is suggested to be standard treatment for DDLPS, neoadjuvant or adjuvant therapy could reduce the risk of recurrence. Systemic therapy combined with surgery can be considered in the treatment of selected patients with localized DDLPS, particularly in patients whose primary tumor is considered borderline resectable or near other anatomically critical structures. However, no prospective reports have shown a survival benefit from neoadjuvant or adjuvant chemotherapy in patients with DDLPS .Similar to other DDLPS, the first-line chemotherapy regimens for vaginal DDLPS are still base on anthracycline, and the common chemotherapy regimen is single-agent anthracycline or anthracycline in combination with ifosfamide. Ifosfamide, an alkylating agent, is typically combined with pirarubicin in the first-line setting in order to maximize benefit. In the present case, the patient underwent complete surgical resection for the mass. Six courses of a combination chemotherapy of pirarubicin and ifosfamide were administered to the patient, and the patient remains well with no evidence of disease recurrence with 13 months of follow-up, indicating that combination chemotherapy with pirarubicin and ifosfamide may be effective for treating vaginal DDLPS.Although anthracycline-based chemotherapy remains the standard treatment for selected patients with DDLPS after surgery, recent study has shown a number of systemic agents have clinical benefit for patients with metastatic or unresectable DDLPS . The optDedifferentiated liposarcoma is an aggressive and high-grade form of liposarcoma. Liposarcoma is very rare in female genital tract, and more rare for DDLPS in gynecologic field. Correct diagnosis is extremely difficult before surgical resection. The diagnosis of DDLPS depend entirely on postoperative pathology. We have presented, to the best of our knowledge, the first case of DDLPS deriving from the vagina. The patient remains well with no evidence of disease recurrence after complete surgical resection followed by six courses of systemic chemotherapy, indicating that combination chemotherapy with pirarubicin and ifosfamide may be effective for treating vaginal DDLPS. Novel therapeutic strategies are needed for better outcomes in patients with DDLPS.


Splenic artery pseudoaneurysm (SAP) is an uncommon etiology of acute abdominal pain, requiring a high degree of clinical suspicion to diagnose in a timely manner. There are currently no reports of spontaneous SAP ruptures in the emergency medicine literature. We report a case of a man who presented with acute abdominal pain secondary to an SAP. A computed tomography angiography scan of the abdomen revealed a ruptured SAP with hemoperitoneum. He successfully underwent emergency laparotomy and surgical ligation of his SAP with splenectomy. SAP rupture remains an under-recognized etiology of abdominal pain, even though it is the most frequent type of visceral pseudoaneurysm. Our case herein reinforces the importance of a broad list of differential diagnoses in the patient with acute abdominal pain, as well as the importance of the emergency physician in identifying an emergent condition and then directing the initial stabilization, resuscitation, and management. Splenic artery pseudoaneurysm (SAP) is a rare entity, with less than 250 cases reported in the literature, but critical to recognize in the acutely ill patient ,2. PatieThe most common presentation of SAP is gastrointestinal bleeding, which typically occurs from the SAP hemorrhaging into the gastrointestinal tract via the pancreatic duct . Acute aA 36-year-old Hispanic man presented to the emergency department complaining of acute-onset, progressive, sharp, stabbing, colicky left upper quadrant abdominal pain radiating to his left flank that began one hour prior to evaluation. The patient denied any recent trauma but endorsed a history of previous open laparotomy and bowel resection after suffering a stab wound in his left-upper quadrant six years prior.On physical examination, he was uncomfortable appearing and in moderate distress secondary to pain. His temperature was 36.8°C, blood pressure 110/90 mmHg, heart rate of 114 beats per minute, respiratory rate of 18 respirations per minute, and oxygen saturation 98% on room air. He had warm extremities and equal pulses in his bilateral upper extremities. His abdomen was firm, non-distended, and diffusely tender to palpation with voluntary guarding.Bedside focused assessment with sonography in trauma (FAST) exam was positive for intra-abdominal free fluid and a large hematoma in the left-upper quadrant. He had a normocytic anemia, with a hemoglobin of 12.1 g/dL, a hematocrit of 35.3%, and lactic acid of 2.3 mmol/L, while all other labs, including lipase, were within normal limits. The patient was resuscitated with two liters of normal saline and underwent a computed tomography (CT) angiography of his abdomen and pelvis. It revealed a 6.8 x 5.1 x 6.6 cm splenic hematoma with an actively extravasating 1.3 x 1.2 cm SAP, hemoperitoneum, and adjacent mesenteric stranding in the adjacent bowel  of transcatheter embolizations are unsuccessful, requiring subsequent surgical intervention. SAP size is not an accurate determinant of rupture, as some of the smallest (0.3 cm) and largest (17 cm) SAPs in the literature have ruptured, although this may be subject to publication bias and no high-level studies have investigated asymptomatic pseudoaneurysms [4% of traThere is only one other reported case of unprovoked, spontaneous SAP rupture to date, in a critically ill patient who presented with altered mental status, abdominal pain and hemorrhagic shock . He was This patient’s insidious presentation combined with SAP rupture’s rarity reinforces the importance of a broad list of differential diagnoses in the patient with acute abdominal pain, as well as the importance of the emergency physician in identifying an emergent condition and then directing the initial stabilization, resuscitation, and management. The patient’s profound abdominal tenderness and history of known exploratory laparotomy and bowel resection initially raised the possibility of an early small bowel obstruction. However, a wide differential included other intra-abdominal infections , nephrolithiasis, pulmonary embolism, acute pancreatitis, and mesenteric ischemia. Given the patient’s normocytic anemia and continued pain despite opiate administration, finding a source for presumed hemorrhage was essential to clarifying the etiology of his symptoms. The patient did not have any signs or symptoms of gastrointestinal bleeding; therefore, a point of care ultrasound was performed, which demonstrated intra-abdominal hemorrhage and a hematoma in the left upper quadrant. In the absence of clear gastrointestinal or intra-abdominal bleeding, clinicians should consider occult sepsis, hemolysis, bone marrow failure, renal failure, membrane defects, and enzyme deficiencies as the underlying etiologies of anemia .Hemorrhagic shock caused by SAP rupture without evidence of gastrointestinal bleeding is uncommon but critical to accurately diagnose and manage, given the high mortality rate if left untreated. Our patient’s presentation highlights the importance of a broad list of differential diagnoses in the patient with acute abdominal pain, as well as a structured approach to the initial evaluation and aggressive management of patients with hemorrhagic shock. As in our patient’s case, multidisciplinary involvement, including interventional radiology and surgical consultation, should be sought early in cases of ruptured SAP.


Associations between neuropsychotic changes and oncologic disease are often described as late-onset symptoms, secondary to the instituted treatment. However, neurocognitive symptoms as a clinical manifestation of adnexal tumors are still little discussed, despite the importance of these in the gynecology practice. In this article, we present a case of adnexal mass whose first clinical manifestations were neuropsychiatric alterations. Such changes led the patient to seek our health service, and after diagnosis and treatment of the ovarian mass, the patient presented remission of the symptoms. Adnexal masses are inherent to the gynecology practice, in any age group. A woman has a chance from 5% to 10% of having surgery due to adnexal mass in her life Muto, 2016). The wide variety of possible diagnoses facing an additional mass lead to many possibilities regarding evolution and symptoms. Despite the lack of formal statistical data, neurocognitive alterations are described as a possible clinical manifestation of adnexal tumors. Ovarian cancer typically presents with 3–4 months of abdominal pain or distension, which might be mistakenly attributed to irritable bowel syndrome [016. The A 59-years-old woman, Caucasian, divorced, who works at home, was taken to the hospital by relatives presenting humor alterations, described as hypotimia and melancholy, inappetence, and constipation for three days. There is history of the following unspecified mental behavior for at least 10 years without diagnosis or treatment until admission to this service and diagnosis of adnexal mass. About the gynecological and obstetric history, she had menarche at fifteen and she had menopause at 42. Beginning of sexual life was at 22, having a partner in life. She had three pregnancies, two vaginal deliveries and one cesarean section. For personal history, she was unquantified long-time smoker. She denied any other health conditions. We could not gather family history due to the patient's clinical conditions upon coming to our health service. During physical examination, the patient was in regular general condition, pale, conscious, oriented in time and space, and making small contact. The abdominal examination revealed a mass of imprecise limits, hardened and nonpainful, from the pelvis to 1 cm above the umbilical scar, with no inflammatory signs. Bowel sounds were present, at a reduced frequency. The complementary investigation was made with abdominal and pelvic computed tomography, which described the abdominal mass identified at physical examination was the right annex, cystic, regular, and homogeneous. It had no contrast uptake and had large central septa , and impaired criticism, with no alteration in orientation to space, to the current time, and to herself. Although there were no signs of bowel obstruction at the CT scan, it was decided to place a nasogastric tube due to the anorexia and elimination of gases and feces arrest, with debt of 1700 mL. Exploratory laparotomy was then indicated. After opening the cavity, a massive solid-cystic formation corresponding to the right ovary was observed, besides a normal-looking uterus and left ovary . There wDuring the postoperative period, the patient showed contact from the first day, with significant improvement of the neuropsychiatric alterations previously described: normal course of thought, form, and content, without memory impairment, preserved criticism, and euthymic humor. This improvement was maintained during the three days of hospitalization in the postoperative period, being considered, therefore, stable.Despite the evolution of diagnostic methods such as ultrasonography, extensive tumor growth resulting in large ovarian masses is relatively a common finding, especially in malignant tumors, in which the rapid evolution of the disease implies advanced symptomatology in a short period , 5. HoweAbout the ovarian tumors, a rare group of symptoms may be present: neurocognitive disorders, detected in this case. Cancer patients as a whole may present, during disease evolution, changes in psychic functions . Neurological and behavioral changes are often associated with leptomeningeal carcinomatosis, and it is an uncommon and typically late complication of ovarian cancer . In this