It can be because of an underlying fistula.•CT fistulogram is the investigation of choice to confirm the diagnosis.•Operative intervention is difficult but the only method of cure in most of the circumstances. Peptic perforation repair is a common stomach surgery. This surgery has not been associated with delayed onset gastrocutaneous fistula formation. However such a complication has been reported following a variety of other stomach surgeries. We are reporting this case as it is a rare complication. Also its diagnosis and management is challenging.We are presenting a case of peptic perforation repair where burst abdomen happened in the immediate post-operative period. The patient was put on conservative management. He responded well to it but his abdominal wound was not healing. After a wait of four months the wound was covered with a skin graft. The graft uptake was satisfactory but a discharging ulcer appeared on it. This condition persisted for one month. Finally a computed tomography Fistulogram (CT Fistulogram) was performed. It revealed an underlying complex gastric fistula. A repeat surgery was performed.A gastrocutaneous fistula diagnosed at sixth month following the peptic perforation repair and causing minimal discomfort to the patient is a rare presentation. The abdominal wound following the surgery was possibly not healing because of the underlying fistula. Early in post-operative period they manifest as burst abdomen with copious discharge through the wound. The late manifestations can be subtle and usually present as discharge through the scar. Internal fistulas to other organs are also known to occur. Their course is unpredictable. Some heals spontaneously while others require meticulous surgery. This wide spectrum of presentation and progress should always be kept in mind. Even a small suspicion should be thoroughly investigated. It is important to reach a proper diagnosis before intervention. We are reporting a rare complication of peptic perforation repair from a tertiary care academic institute. The work has been reported in line with the SCARE criteria .22.1A 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.The examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation . A scar 2.23/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous surgery site an upper GI endoscopy was performed. A small benign looking ulcer was seen at the pylorus of the stomach.The blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 10With a strong suspicion of gastrocutaneous fistula, a CT fistulogram was performed. An enterocutaneous fistula between the pylorus of the stomach and the anterior abdominal wall was seen. A long side branch of the fistula tract was seen communicating to a moderate sized left subphrenic collection .Fig. 2Ax2.3With confirmed diagnosis of complex gastrocutaneous fistula a repeat surgery was planned. The abdomen was entered after incising the previous scar on left lateral side and extending the incision downwards and upwards. Dense interbowel adhesions were encountered. Meticulous adhesiolysis and dissection was performed. The abscess cavity was drained and the perforation on the pylorus of the stomach was identified. It was around 1 cm × 1 cm size. Repeat omental patch repair was performed. In view of difficult dissection, feeding jejunostomy and retrograde tube duodenostomy were also made.2.4An uneventful recovery happened. He attended follow up clinic till 4 months following the discharge. There was an incisional hernia but otherwise he was doing fine. After this he was lost to follow up.Timeline3Clinical presentation of leaked a peptic perforation repair is usually violent. They are high output fistulas and requires good nutritional support along with control of effluents . The preThe only thing that does not fit well into this is the fact that the burst didn’t healed spontaneously. At fourth month it required skin grafting. A fairly large time was given for the wound to heal on its own. The built, nutrition, general condition and laboratory parameters were all favouring the healing. He was not immune suppressed or addicted to any substance. Neither he had any other co-morbidity. Non healing in such a person is difficult to explain.The late formation of the gastric fistula is a reported event in the literature. Although never described in relation to peptic perforation, it has been described following a variety of gastric surgeries . These iThe diagnosis of gastric fistula is a challenging task. A strong clinical suspicion is necessary. Ultrasound abdomen and Upper gastrointestinal endoscopy are not diagnostic. CT Fistulogram is the investigation of choice in these circumstances ,8.Management of gastric fistulas is complex. Spontaneous healing sometimes happen when the fistula is simple. Presence of distal obstruction, local sepsis, multiple tracts or large defect excludes this possibility. Spontaneous healing after two months of surgery is also rare. In these circumstances surgery is the only option. The ideal time for intervention is between three to six months after the primary surgery when the patient is stable. The surgery is usually difficult because of dense adhesions. Minimal access procedures have been tried especially in bariatric and paediatric patients ,5,9. CerOn retrograde evaluation the skin grafting was a controversial decision. Even though the graft uptake was near complete and patient was symptom-free for almost four weeks. A complete radiological workup including contrast enhanced CT scan could have been a more appropriate clinical decision.Nil.Nil.Exempted from ethnical approval of 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.Not applicable.Dr Mithilesh Kumar Sinha.Not commissioned, externally peer-reviewed.Mithilesh Kumar Sinha: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Visualization, Writing - original draft, Writing - review & editing. Sudipta Mohakud: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing - review & editing. Tushar Subhadarshan Mishra: Conceptualization, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing - review & editing. Apurba Barman: Conceptualization, Formal analysis, Validation, Visualization, Writing - original draft, Writing - review & editing.


Esophageal duplication cysts are rarely encountered in adult patients. Complete cyst resection is achievable employing video‐assisted thoracoscopic surgical techniques, with low morbidity and excellent cosmesis. Esophageal duplication cysts are rarely encountered in adult patients. Complete cyst resection is achievable employing video‐assisted thoracoscopic surgical techniques, with low morbidity and excellent cosmesis. Hematology and biochemistry laboratory tests were within normal limits, and standard chest radiography did not reveal any lung or mediastinal lesions.Contrast‐enhanced computed tomography of the chest showed a well‐defined 3 × 3.5 × 4 cm homogeneous mass on the right side of the distal esophagus, proximal to the gastro‐esophageal junction Figure . TransesDecision was made to perform elective excision of this mass lesion and, since the distal esophagus is usually more accessible from the left, this was carried out employing a left‐sided video‐assisted thoracoscopic surgical (VATS) approach. Using three 5‐mm ports, the lower esophagus was dissected and the mass was identified Figure . AttemptThere were no postoperative complications. The patient returned gradually to full oral intake and was discharged home on the fourth postoperative day in an excellent general condition. He remains symptom‐free after 4 months of follow‐up. Histology confirmed the lesion to be an EDC, with dual muscular layer and a characteristic columnar ciliated epithelial lining surrounded by severe chronic inflammatory infiltrate.3Open surgical resection via conventional posterolateral thoracotomy has long been the standard approach to the treatment of EDCsPublished experiences to date with the VATS approach to EDCs have predominantly been in managing pediatric patients, whereas reports of VATS resection of EDCs in adults are still limited to a handful of cases only.This report extends contemporary archives on the use of VATS techniques to the removal of intramural EDCs in adult patients. Complete VATS resection of an EDC was both safe and achievable with low morbidity and excellent cosmesis. We propose that this approach may be the new surgical technique of choice.None declared.Bassam Darwish: contributed to conception and acquisition of data, drafted the manuscript and revised it critically, and gave final approval of the version to be published. Mohammad Bashar Izzat: contributed to conception and acquisition of data, drafted the manuscript and revised it critically, and gave final approval of the version to be published.All procedures performed in this study were in accordance with the ethical standards of the Damascus University Research Ethics Committee and with the 1964 Helsinki declaration and its later amendments.Informed consent was obtained from all individual participants included in the study.


As advancements are made in the management of cystic fibrosis (CF), survival of the CF patient into adulthood has increased, leading to the discovery of previously unknown CF complications. Though gastrointestinal complications of CF, such as distal intestinal obstruction syndrome, are common, this case demonstrates a variant presentation of small bowel obstruction in this population.We describe a 42-year-old male with CF who presented with 2 days of worsening upper abdominal pain, emesis, and loss of bowel function. The patient had no history of any prior abdominal surgeries; however, imaging was concerning for high-grade mechanical small bowel obstruction possibly related to internal hernia. Given leukocytosis and diffusely tender abdomen found on further workup, the decision was made to proceed with diagnostic laparoscopy after a brief period of intravenous fluid resuscitation. Intraoperatively, the transition point was found in the mid-jejunum and was noted to be due to kinking of the bowel causing vascular congestion in the proximal portion. Surgical manipulation of the bowel was required for return of normal perfusion and patency.Though the exact mechanism cannot be definitively delineated, we speculate that the increased viscosity and prolonged intestinal transit time, characteristic of CF, resulted in inspissated fecal content in the proximal small bowel, which then acted as a lead point for obstruction. Thus, though small bowel obstruction in patients with CF is often attributed to distal intestinal obstruction syndrome, a broader differential must be considered. Early surgical intervention may be necessary to prevent bowel ischemia and subsequent small bowel resection in a patient presenting with concerning clinical and image findings, as was seen in this patient. In the span of a decade 2000–2010), advancements in screening and management have led to a 1.8% yearly increase in survival of cystic fibrosis (CF) patients [0, advancA 42-year-old male with CF presented with 2 days of persistent, worsening bilateral upper abdominal pain, non-bloody non-bilious emesis, and constipation. His last bowel movement occurred approximately 36 h prior to presentation, despite the use of two enemas. The patient denied any prior history of similar abdominal pain and states his regimen of polyethylene glycol 3350  2–3 times per week has normally maintained his bowel habits at one to two soft stools daily. Surgical history was negative for any prior abdominal surgeries. Review of systems was negative for symptoms concerning for malignancy.On exam, vital signs were within normal limits. The patient was visibly uncomfortable and diaphoretic, with diffuse abdominal tenderness to palpation, worse in the left upper quadrant, mildly distended, though soft. There was no evidence of umbilical or inguinal hernias. Further workup revealed leukocytosis of 11,500 with left shift and normal lipase.CT abdomen/pelvis with and without intravenous contrast demonstrated a high-grade mechanical small bowel obstruction, possibly related to internal hernia, with a transition point in the left lateral hemiabdomen Fig. c and infGiven the exam findings, leukocytosis, and high-grade mechanical obstruction with transition point found on imaging, the patient was taken to the operating room for exploration after a brief resuscitative period with intravenous fluids. Consents were obtained for possible bowel resection and/or ostomy and counseling on the possibility of encountering a mass/tumor.The decision was made to proceed with a diagnostic laparoscopy, with low threshold for converting to laparotomy if visibility was an issue. Veress needle at the umbilicus was used to achieve pneumoperitoneum, and a 5-mm trocar was placed at the umbilicus using a camera through a clear trocar. Given good visibility, additional 5 mm trocars were placed in the right upper and right lower quadrants.The small bowel was ran from the ligament of Treitz to the ileocecal valve, revealing significant dilation and vascular congestion from the distal duodenum through the mid-jejunum Fig. . There wPostoperative management included 12 h continuous polyethylene glycol solution at 100 cc/h via nasogastric tube. Following return of regular bowel function on postoperative day 2, he was discharged home with increased bowel care.CFTR mutations resulting in deranged function of the cystic fibrosis transmembrane conductance regulator (CFTR). The lungs, pancreas, and intestines are usually affected by impaired secretion, absorption, and motility. In the gastrointestinal (GI) tract, reduced chloride and fluid secretion via the CFTR membrane protein, combined with enhanced sodium and fluid absorption via the epithelial sodium channels (ENaC), increases intraluminal viscosity [CF is an autosomal recessive disease caused by a heterogeneous spectrum of iscosity . Myenteriscosity . These iDIOS is characterized as an acute, complete or incomplete, intestinal obstruction of viscid fecal accumulation in the ileocecal region , 4. It hThe case presented here represents a separate entity from DIOS owing to its unique location and mechanism of obstruction. The patient’s tenderness was localized to the LUQ, without significant tenderness or masses in the RLQ, as is common in DIOS. Rather than an ileocecal location (common in DIOS), CT imaging in our patient demonstrated a proximal obstruction on the left which was confirmed to be mid-jejunal intraoperatively. Additionally, the obstruction was noted to be mechanical—secondary to kinking of the bowel onto itself. Though the exact mechanism cannot be definitively delineated, we speculate that the increased viscosity of the intestinal contents and prolonged intestinal transit time, characteristic of CF, resulted in inspissated fecal content in the proximal small bowel Fig. , which aAlthough small bowel obstruction in patients with CF is often attributed to DIOS and treated medically, a broader differential must be considered to determine appropriate management. Early surgical intervention may be necessary to prevent bowel ischemia and subsequent small bowel resection in a patient presenting with concerning clinical and image findings.


Dedifferentiated liposarcoma is rare and tends to present with discrete tumors in the retroperitoneum, limbs and trunk. Majority of cases arise de-novo as primary tumors, while a minority occur as recurrences of well-differentiated liposarcomas. There has been no previous report of dedifferentiated liposarcoma presenting as disseminated intraperitoneal sarcomatosis.This report describes a young Asian female with disseminated intraperitoneal sarcomatosis arising from de-novo dedifferentiated liposarcoma, and discusses the diagnostic challenges faced in this highly unusual disease presentation. Initial biopsy was unconclusive, and considerations included sclerosing mesenteritis or an inflammatory myofibroblastic tumor. Fluorescence in situ hybridization was subsequently performed and showed amplification of the MDM2 gene. A diagnosis of dedifferentiated liposarcoma was then made.This was an extremely unusual presentation of advanced dedifferentiated liposarcoma that was eventually diagnosed using fluorescence in situ hybridization. Prognosis is poor and the only viable treatment options was palliative chemotherapy.The diagnosis of dedifferentiated liposarcoma should be considered early and surgery carried out when still feasible. It typi2The patient is a 37-year-old Asian female with a past surgical history of laparoscopic cholecystectomy for symptomatic cholelithiasis and excision of breast fibroadenomas. She has no other past medical history or significant family history of cancer. She is a smoker of 17 pack-years but does not drink alcohol.The patient presented with a 1-month history of vague abdominal discomfort and weight loss, and noticed a left abdominal mass 1 week prior to presentation. She denied any early satiety, change in bowel habits, jaundice, melena, or hematochezia. The patient was well nourished, with no signs of anemia. Physical examination revealed a soft abdomen with a palpable left flank mass. This mass was firm, and did not move with respiration. There were no palpable lymph nodes in her supraclavicular fossae, neck and groin.9/L . Her renal function and liver function were normal. Tumor marker tests were also done, and this showed that her cancer antigen-125 (CA 125) was elevated at 225U/ml  but cancer antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP) were within normal limits.A computed tomography (CT) scan was arranged, and this showed an intra-peritoneal mass of indeterminate origin in the left flank, with extensive peritoneal and omental nodules. Blood tests revealed that her hemoglobin was 13.6 g/dL  and her white cell count was 7.04 × 10She then underwent esophagogastroduodenoscopy and colonoscopy which did not show any intraluminal lesions. A positron emission tomography-computed tomography (PET-CT) scan was performed and confirmed the presence of a fluorodeoxyglucose (FDG)-avid mass in the left flank with extensive omental and peritoneal nodules, but no definite primary was identified . There wThe patient was referred to a specialized peritoneal malignancy unit, and the case was discussed at the multidisciplinary tumor board meeting. In light of the imaging findings, a recommendation was made for image-guided percutaneous biopsy of the left flank mass. This biopsy showed spindle cells within a loose stroma with mild nuclear atypia and few mitotic figures A. No necDuring the follow up visit, the patient complained of worsening abdominal discomfort and repeat imaging showed enlargement of the peritoneal nodules within a short span of 3 weeks. After discussion with the patient, a decision was made for a diagnostic laparoscopy and surgical resection of the left flank mass for symptomatic relief and additional tissue for a more definitive diagnosis.Intraoperative findings showed extensive peritoneal disease with a peritoneal cancer index (PCI) score of 35 . The culFormal histopathologic examination of the omental tumor showed a moderately cellular spindle cell proliferation in short fascicles with occasional storiform arrangement. The spindle cell proliferation was admixed with adipose tissue in an irregular, occasionally lace-like pattern A. The ceImmunohistochemistry was performed and the spindle cells stained positive for SMA, and negative for desmin, caldesmon, CD34, CD21, CD35, ALK, and EBER-ISH. Beta-catenin showed largely cytoplasmic staining. Fluorescence in situ hybridization (FISH) using MDM2/CEP12 probe set was subsequently performed and 88.3% of 60 tumor nuclei scored showed amplification of the MDM2 gene at 12q15. The ratio of MDM2 to CEP12 signals was 5.3. A diagnosis of dedifferentiated liposarcoma (FNCLCC grade 2) was made.The patient recovered well post-operatively and was discharged on post-operative day 2. Based on the final histology result of a dedifferentiated liposarcoma, she was referred to the medical oncology team and started on doxorubicin chemotherapy.3Dedifferentiated liposarcomas typically occur as discrete tumors in the retroperitoneum, limbs, and trunk. The presentation as disseminated intra-abdominal nodules in this patient was highly unusual and proved to be a diagnostic conundrum. The histologic appearance of proliferating spindle cells with significant admixed inflammatory infiltrates, coupled with an absent adipocytic component in the first biopsy also led to an initial diagnosis of sclerosing mesenteritis or an unusual form of inflammatory myofibroblastic tumor .Dedifferentiated liposarcomas are histologically characterized by a non-lipogenic sarcoma which is often high grade. A well-differentiated component may be present. Amplification of the MDM2 gene is demonstrated in 95% of liposarcomas by FISH . This chThe cornerstone of treatment for liposarcomas is complete surgical resection, which can be difficult to achieve in abdominal tumors due to their close proximity to vital structures. Given the high local recurrence rates for intra-abdominal and retroperitoneal liposarcomas, radiation therapy can be considered as an adjunct to surgery. The benefit of neoadjuvant radiotherapy in retroperitoneal sarcomas is currently being examined in the STRASS trial ,41. Unfoth International Workshop on Peritoneal Surface Malignancy. It concluded that evidence supporting HIPEC or EPIC for peritoneal sarcomatosis was insufficient. Little has been discussed with respect to systemic therapy options in peritoneal sarcomatosis arising from liposarcomas. The rarity of these presentations has proven to be the greatest barrier to the conduct of formal clinical trials [To date, there have been 4 retrospective single-institution series and 1 phase I study examining the role of cytoreductive surgery (CRS) and intra-peritoneal chemotherapy in the treatment of peritoneal sarcomatosis . Howeverl trials .Response rates to chemotherapy for dedifferentiated liposarcomas has been reported to be ≤12% . Doxorub4This case report describes an unusual presentation of disseminated intraperitoneal sarcomatosis and its associated diagnostic challenges. Perhaps earlier diagnosis could have led to earlier commencement of treatment. The benefit of chemotherapy for this patient, however, remains uncertain. Novel targeted therapies involving MDM2 and CKD4 inhibitors are currently being evaluated and may change the landscape of systemic therapy for liposarcomas in the future .The authors declare that there is no conflict of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This case report is exempt from ethical approval in 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.Cai Mingzhe – Data collection and writing of paper.Caroline Siew Ching Hsia – Study concept and writing of paper.Timothy Tay Kwang Yong – Data collection and writing of paper.Grace Tan Hwei Ching – Study concept, writing of paper and overall supervision.http://www.researchregistry.com UIN: researchregistry4923Grace Tan Hwei Ching.Not commissioned, externally peer-reviewed.


Radiation enteritis following radiotherapy targeting the abdomen occasionally causes ulcers or ileus, which can be difficult to treat and usually progressive and refractory, significantly degrading the patient’s quality of life.A 58-year-old woman had undergone surgery for cervical cancer approximately 21 years ago. During treatment, she had also received radiotherapy targeting the pelvis and stomach. She presented with complaints of vomiting and lower abdominal pain and was subsequently diagnosed with multiple gastric ulcers, enterocolitis, and paralytic ileus due to late radiation-induced sequelae. We reasoned that visceral sympathetic block would improve the abdominal symptoms; therefore, we performed a splanchnic nerve block and an inferior mesenteric artery plexus block. As predicted, these block procedures improved the symptoms.Radiation enteritis is an iatrogenic disease, and there is no established treatment for intractable cases. However, visceral sympathetic nerve block may show efficacy as a potential therapy for radiation enteritis-associated abdominal pain and ileus. Radiation enteritis following radiotherapy targeting the abdomen occasionally causes ulcers or ileus, which can be difficult to treat. We report on the case of a woman suffering from paralytic ileus and abdominal pain due to radiation enteritis as a result of radiotherapy after previous cervical cancer surgery. Splanchnic nerve block and inferior mesenteric arterial plexus block procedures improved both the abdominal pain and the ileus symptoms.We obtained comprehensive consent beforehand from the patient, and we obtained consent to report the clinical experience and publish the accompanying images.The patient was a 58-year-old woman suffering from lower abdominal pain and vomiting, which gradually worsened from the start of December 2017. An upper gastrointestinal endoscopy revealed multiple gastric ulcers and scars, and lower gastrointestinal endoscopy revealed inflammation in the large intestine. The patient had undergone surgery in 1997 for cervical carcinoma, followed by postoperative radiotherapy that involved irradiation of her pelvis and stomach. On the basis of the symptoms, endoscopy findings, and medical history, the patient was diagnosed with refractory multiple gastric ulcers, enterocolitis, and paralytic ileus due to late radiation-induced sequelae.As a result of frequent vomiting, the patient had become unable to ingest orally. She was hospitalized in October 2018 and fasted before being placed under central venous nutrition control. Hyperbaric oxygen therapy was started to treat the intractable multiple gastric ulcers and ileus. Thirty treatment sessions were scheduled over a period of approximately 1–2 months. Pentazocine and tramadol were administered to treat the abdominal pain, but these achieved poor results.At hospitalization, the patient was 155 cm tall and weighed 43 kg. Although she exhibited abdominal distention, no muscular defense or rebound pain was observed. On percussion, the bowel sound was attenuated. A blood examination revealed anemia, slight liver dysfunction, low protein levels, and hypoalbuminemia. An abdominal X-ray showed several small intestinal niveau and extension of the colon and small intestine by intestinal gas . An abdominal X-ray was performed after the block procedure, showing the number of intestinal niveau and the amount of gas had decreased, as compared to that before the block  scan showed dilation of the small intestine, as well as the formation of niveau; however, no bowel obstruction or disruption of blood flow was observed Fig. a.Fig. 2aAn upper gastrointestinal contrast examination with contrast medium  showed relatively good peristaltic movement of the large and small intestine but poor gastric peristaltic movement. A large amount of food residue was also observed. An epidural catheter was inserted via the thoracic 6–7 intervertebral space for innervation of the upper gastrointestinal tract, including the stomach and small intestine, and continuous epidural anesthesia with 0.2% ropivacaine at 4 ml/h was started. This alleviated the abdominal pain, and the vomiting disappeared.Approximately 2 weeks later, continuous epidural anesthesia was stopped, and a splanchnic nerve block with ethanol was performed Fig. . The subRadiation enteritis is an iatrogenic disease, with no established treatment for intractable cases. However, the results of the present case suggest that a sympathetic nerve block procedure in the abdomen, such as a splanchnic nerve block or inferior mesenteric plexus block, may improve symptoms associated with radiation enteritis. It is widely accepted that these blocks are effective for intractable abdominal pain, but there has been no previous report about their effects on ileus. To the best of our knowledge, this is the first report detailing the therapeutic benefit of block procedures in the treatment of ileus by enhancement of the peristaltic motion of the intestines through suppression of the sympathetic nervous system.Radiation enteritis caused by radiation therapy is classified as either early or late according to whether it occurred within 3 months of or 6 months after irradiation, respectively. Early radiation enteritis manifests as reversible injury of the intestinal mucosa and watery diarrhea, with normal recovery after the irradiation ends. On the other hand, late radiation enteritis is thought to be caused by intestinal ischemia and fibrosis caused by radiation endarteritis and subsequent thrombotic microcirculatory disturbances, causing pathological conditions such as enteritis and ileus. Late radiation enteritis is clinically problematic; the late sequelae are usually progressive and refractory, significantly degrading the patient’s quality of life .The radiation enteritis in the present case developed more than 10 years after radiotherapy treatment, similar to a previous case report that describes the sudden development of radiation enteritis after a long period of time . In our When the late sequelae include stenosis, perforation, and fistula formation in the intestinal tract, surgical treatment is recommended. However, the present case was not considered for surgical treatment because there was no evidence of occlusion or stenosis of the intestinal tract. Moreover, surgery should be avoided where possible because it promotes the adhesion of the intestinal tract. In this case, there was no routine treatment option; the patient was administered hyperbaric oxygen therapy, inhaling oxygen at a high concentration to raise the environmental pressure to 2 atm or more using hyperbaric oxygen therapy apparatus. Hyperbaric oxygen therapy is an established treatment for conditions such as gas gangrene, carbon monoxide poisoning, cerebral infarction, and intestinal obstruction –7. It haIn this case, abdominal sympathetic systems were implicated in the patient’s ileus. Previous studies have shown that sympathetic nerve blocks increase intestinal blood flow and improve intestinal motility and wall tension , 13. MorIn conclusion, in this case of paralytic ileus caused by radiation enteritis, a splanchnic nerve block and a mesenteric arterial block were performed for analgesic purposes and to release the ileus. Sympathetic nerve blocks for abdominal organs may offer one of the few treatments for radiation enteritis.


Background: Fibroepithelial polyps of the urothelial system are rare and are considered to be benign tumors. Ultrasonography (USG), contrast-enhanced CT, and contrast-enhanced MRI can be used for detecting fibroepithelial polyps in the urothelial system. These polyps can be treated by performing open exploration and endoscopic or laparoscopic resection. Previous studies have also reported the frequent use of laser treatment for treating fibroepithelial polyps located in the proximal ureter.Case Presentation: A 54-year-old female patient presented to our clinic with right flank pain. Evaluation of the patient by performing USG and CT detected grade-2 hydronephrosis of the right kidney; however, no stone was detected in the urinary system. MRI detected thickening of the wall of the right proximal ureter along with contrast enhancement. These findings suggested the presence of a ureteral polyp. Ureterorenoscopy detected a 7-cm-long ureteral polyp in the proximal ureter, which was resected by performing monopolar cautery.Conclusion: Although fibroepithelial polyps of the urinary tract are rare, they should be considered in the absence of urinary calculi and in the presence of a ureteral obstruction. Furthermore, careful endoscopic resection by performing electrocautery is a safe and useful method for treating ureteral lesions. Although fibroepithelial polyps are rare, they are the most common benign tumors of the ureter.2 It is important to distinguish between fibroepithelial polyps and urothelial carcinoma because these two conditions require different management strategies and show different prognosis. Although open exploration and resection have been used previously for treating fibroepithelial polyps, less invasive approaches are used at present. In this study, we report the case of a patient with a fibroepithelial polyp in the proximal ureter that was treated by performing resection with ureterorenoscopy.TA 54-year-old female patient presented with colic right flank pain. She did not have any urinary tract infection, stone, or tumor in her history. Urinalysis did not detect microscopic hematuria or pyuria. Moreover, her renal functions were normal, and urine culture did not yield any abnormal findings. Ultrasonography (USG) detected grade-2 hydronephrosis of the right kidney. Noncontrast CT did not detect any stone in the urinary system. However, intravenous urography (IVU) detected filling defects in the right proximal ureter . MRI det2 These polyps contain stroma derived from the mesoderm and are covered by a layer of normal transitional epithelial cells. Although the etiology of these tumors has not yet been clearly understood, it is suggested to be associated with congenital, irritative, infectious, obstructive, and traumatic causes. The most frequent clinical findings of patients with fibroepithelial polyps are flank pain and hematuria. Moreover, these patients may present with less common findings such as urinary frequency, dysuria, or pyuria. The first diagnostic evaluation of all patients should include IVU, contrast-enhanced CT, or contrast-enhanced MRI. Determination of filling defects by performing antegrade or retrograde pyelography may also help in diagnosis. Clinical symptoms and results of imaging tests are inadequate for the definitive diagnosis of fibroepithelial polyps. The definitive diagnosis of fibroepithelial polyps can be established by performing histopathological analysis. Biopsy or resection by using open, endoscopic, or laparoscopic techniques should be performed to obtain specimens for performing histopathological analysis of fibroepithelial polyps. Debruyne et al. reported that 41 (37%) unnecessary nephrectomies were performed in 108 patients because of an uncertain preoperative diagnosis.3 Ureterorenoscopy is also useful for differentiating between benign and malignant ureteral lesions.A ureteral fibroepithelial polyp was first reported in 1932. Fibroepithelial polyps most commonly develop in adults and children. Moreover, their incidence is more common in men in the third or fourth decade of life than in women.1 Franco et al. reported that none of the patients with fibroepithelial polyps showed malignant transformation.4 In some patients, fibroepithelial polyps may be accompanied with transitional cell carcinoma. Moreover, fibroepithelial polyps may develop in different locations in the urinary system, including the ureter, renal pelvis, bladder, and urethra.Fibroepithelial polyps typically present as smooth, mobile, and pedunculated masses in the ureter.To date, no study has compared the efficacy of holmium laser treatment with that of electrocautery. Electrocautery may damage the ureter and surrounding tissues during tumor resection and cauterization. Moreover, electrocautery may result in perforation, adhesion, stenosis, and fistula formation in the ureter after tumor resection. Therefore, electrocautery should be performed carefully to prevent these adverse events. Our patient was treated by performing electrocautery because of the unavailability of laser treatment in our clinic at that time.Previously, fibroepithelial polyps were treated by performing open exploration and resection. At present, with developments in endoscopic and laparoscopic techniques and tools, patients with fibroepithelial polyps can be treated endoscopically, percutaneously, or laparoscopically. Percutaneous antegrade approach is preferred for the ablation of polyps located in the renal pelvis or proximal ureter. Ho-YAG laser treatment or endoscopic cauterization is preferred for treating polyps in the distal ureter that can be reached through a retrograde approach. At present, laser treatment is performed more frequently for treating fibroepithelial polyps located in the proximal ureteral. In our case, the polyp in the proximal ureter was resected by performing electrocautery with ureterorenoscopy. Laparoscopy has been performed to resect large and elongated polyps and is associated with some advantages such as improved visualization and easy working space. Endoscopic resection can be performed safely in patients with small papillary lesions in the ureter. Ureterorenoscopy is a widely used, less invasive, and cost-effective alternative to open and laparoscopic surgery. It is recommended to leave a Double-J stent in the ureter after resection. Ureteral Double-J stents are usually left in the ureter for ∼6 weeks. In our case, the Double-J stent was left in the ureter for 2 weeks after the resection, which is different from that recommended in the literature.In conclusion, although fibroepithelial polyps of the urinary tract are rare, they should be considered in the absence of urinary calculi and in the presence of a ureteral obstruction. Moreover, diagnostic and curative ureterorenoscopy should be performed in patients suspected of having fibroepithelial polyps. In our case, the fibroepithelial polyp located in the proximal ureter was resected by performing endoscopic resection. We believe that careful endoscopic resection by using a laser or cautery can be used for treating ureteral lesions.


Heterotopic gastric mucosa (HGM) is gastric mucosal tissue outside the stomach. It can be discovered anywhere throughout the gastrointestinal tract and is mostly asymptomatic. HGM, although rare beyond the ligament of Treitz, should be included in the differential diagnosis in a young patient with a polyp causing obstructive symptoms or bleeding. Very few cases are published in literature. We describe a case of young male who presented with an episode of large amount of melena, from a bleeding jejunal lesion, diagnosed by endoscopy. Laparotomy and wedge resection of the jejunal lesion was done, and histopathology showed gastric heterotopia in a small jejunal diverticulum. Heterotopia (Greek origin), literally meaning different location, is the presence of a tissue type normally found in the human body but in an abnormal location  and can A 23-year-old male was brought to the emergency of Hamad General Hospital in Doha, after being found on the floor dizzy and confused, with urinary incontinence although no one witnessed convulsions. The patient denied any fever, headache, chest pain, shortness of breath and palpitations, or cardiac diseases.On examination, his pulse was 75 beats per minute, blood pressure 125/78, JVP was not raised, S1 and S2 were normal, and no added sounds on the chest examination. The patient was thought to have had a syncopal attack. His complete blood count and biochemical test were within the normal range. Computed tomography (CT) scan of the head was unremarkable and ECG showed left ventricular hypertrophy and early repolarization. Echocardiography, apart from moderate septal hypertrophy, was otherwise unremarkable.Further history revealed that the patient had an episode of a large amount of melena before the syncopal attack, associated with nausea and two episodes of vomiting, but denied history of alcohol consumption, analgesic intake, and history of liver disease. In the course of time, the patient developed tachycardia of 122 bpm but blood pressure remained normal. His abdomen was soft, lax, nontender, and not distended. No masses were appreciated and bowel sounds were normal. Digital Rectal Examination (DRE) showed melanotic stool. Laboratory results showed a drop in hemoglobin from 13.2 to 8.4 and a high urea of 7.4. He was kept on intravenous fluids and proton pump inhibitors and transfused 2 units of packed red blood cells, and his hemoglobin level was monitored.Esophagogastroduodenoscopy (EGD) showed normal examination up to the third part of the duodenum with no active bleeding or altered blood. Colonoscopy was normal, whereas enteroscopy showed a jejunal diverticulum about 50 cms from the pylorus with fresh bleeding . PatientThe patient underwent diagnostic laparoscopy that did not show any abnormality in the jejunal loops externally. Endoscopy was carried out to localize the jejunal lesion, but it was difficult to pass the scope beyond the duodenojejunal (DJ) junction. Midline laparotomy was performed to guide the enteroscope to the upper jejunum. A small lesion was seen on the serosal surface of the jejunum 30 cm from the DJ junction which endoscopically appeared as a suspicious diverticulum with whitish mucosal plaques. There was no active bleeding or clots. The enteroscope was then pushed further up to 130 cm in the bowel but no pathology was observed. Wedge resection of the suspicious jejunal lesion was carried out. The patient made smooth recovery from the surgery and did not develop further episodes of bleeding. He was last seen in the clinic after 2 years of surgery without any symptoms.Histology showed a small jejunal diverticulum with gastric heterotopic tissue. The specimen consists of a false diverticulum of the small bowel (jejunum) showing a focal, cystically dilated gland within the muscularis propria which, on deeper sections, showed gastric-type mucosal tissue. Focal crypt rupture was noted with mild reaction. The mucosa was unremarkable, and the specimen was negative for dysplasia and malignancy Figures  and 3Gastric heterotopia is an uncommon condition, and it is important to differentiate it from metaplasia. Metaplasia is a change of one type of fully differentiated tissue to another, usually due to sustained inflammation. Heterotopias are developmental anomalies, whereas metaplasia is an acquired condition .Gastric heterotopia has been reported anywhere throughout the length of the gastrointestinal tract, from the oral cavity to the anal canal. It can be congenital as seen in Meckel's diverticulum or intestinal duplication, although it is rare beyond the ligament of Treitz . SalivarHGM consists of full thickness of specialized gastric gland mucosa, containing chief and parietal cells and lined by a single layer of a simple columnar epithelium that is taller than its width (foveolar epithelium). The peptic secretion of these gastric glands is the cause of the intestinal ulcerations observed in cases of HGM , 8.Clinical presentation of HGM varies and depends on the location and size of the heterotopic tissue. It usually presents as an inlet patch in the proximal esophagus, as polypoid masses in the rectum, or as nodular tumors in the duodenum . HGM preThe incidence of HGM in the esophagus varies widely from 0.1 to 13.8% and that in the duodenum from 0.5 to 8.9%. Gastric heterotopias are mostly seen in the duodenum but very rarely in the small intestines, as in our case. [The mechanism for the development of HGM is still not completely elucidated. There are different theories used to explain the etiology . During Some authors have proposed that HGM is the result of an abnormal regenerative process following destruction of normal intestinal mucosa. This hypothesis is not supported by any descriptions of gastric heterotopia following destruction of gastrointestinal mucosa resulting from gastroenteritis or other inflammatory conditions of the intestines . The finHistory-taking and physical examination are important, as they help to suspect the potential diseases involved. Radiologic investigation such as a CT scan, fluoroscopy, capsule endoscopy, and 99mTc pertechnetate scan can usually detect HGM . CapsuleThe definitive diagnosis in all reported cases of HGM in the small intestine was established by histopathological examination of the surgically removed specimens, and surgery was performed for acute complications such as GI hemorrhage or perforation in the majority of cases , 11.Surgery, including resection of the lesion and anastomosis of the healthy bowel ends, has been considered as the treatment of choice whether it is carried out by laparoscopy or laparotomy .HGM is a rare condition and should be considered in the differential diagnosis of upper or lower gastrointestinal bleeding. Diagnosis may be difficult preoperatively but surgical resection offers cure.


Ingestion of foreign bodies including dentures, fishbone, screw, and/or surgical devices can be a cause of morbidity, and it rarely could be fatal.  We present the first hitherto reported case of mussel shell ingestion, which caused acute abdominal pain in a 55-year-old woman. The shell pierced ileal loops, and it was found in the abdominal cavity.  The accidental or voluntary ingestion of a foreign body is an uncommon event compared to the other causes of bowel perforation. It is fundamental to immediately remove the intestinal fluid, repair the tear, and prevent sepsis, because each delay in diagnosis can lead to a worst outcome.  In case of bowel perforation, it important for surgeons, who are dealing with these acute care patients, to be aware of different designs and constructions of possible foreign bodies, in order to be prepared to deal with different possible scenarios and be able to manage them properly. Foreign body ingestion is a commonly seen accident in emergencies –3. It maThe patients gave her consent to the publication of scientific data. The authors declare that there will not be any communication to the third party for the respect of her privacy. This study was written respecting the ethical principles for medical research involving human subjects (Declaration of Helsinki). This article was written according to SCARE 2016 guidelines on case report writing. Since other few cases have been reported, it was not necessary to publish on a public registry.μL, with neutrophilia (90%); other blood tests were in normal range. Body temperature was 39.2°C. Electrocardiogram showed sinus rhythm with 92 heart rate. Chest X-ray was normal. Abdominal X-ray showed free subdiaphragmatic air. CT scan confirmed the suspicion of small bowel perforation because of the finding of free fluid in the abdomen and an inhomogeneous mass in the small bowel. A nasogastric tube was placed, and it drained 50 mL of biliogastric material. Because of her status, she was immediately ran to the theater for exploratory laparotomy under general anesthesia and oral intubation. Although each clinical finding suggested a colonic or caecum perforation, during the systematic exploration of the bowel loops, surgeons found free intestinal fluid in the abdomen, fecal peritonitis, and  a 3 cm linear tear of the ileum which was caused by the curve edge of a shell mussel (A 55-year-old Caucasian obese woman (body mass index = 35) was admitted to Surgical Department of our institution for acute abdominal pain. Her past medical history was negative for previous gastrointestinal disease or surgery. She was on medical therapy for hypertension, type II diabetes, and minor depression. Glasgow coma scale was 15. She referred an increasing acute abdominal pain risen 5 hours ago after a fish-based dinner. She has showed an acute diffuse peritonitis. White blood cell count was 32.000 U/l mussel . The forl mussel , and theThe accidental or intentional ingestion of foreign bodies including dentures, fishbone, screw, magnets, lithium batteries, and/or surgical devices can be a cause of morbidity, but mortality rates have been extremely low. As a matter of facts, a compilation of multiple studies including 2 large series report no deaths in 852 adults and 1 death in 2206 children; mortality rate is extremely low , 5. The Inflammatory bowel disease, appendicitis, diverticula, gallstone migration, cancer, endometriosis, trauma, infection, autoimmune disease, drugs, vasculopathy –13, and


A one and half-year-old boy presented to dental outpatient department with a soft tissue mass hanging from the right upper back milk tooth region for the past 2 days. The patient was asymptomatic and there was no fluid discharge. On clinical examination, it was found that the mass is friable with a size of 0.5 x 0.5cm and the roof of the mass was seen ruptured and hanging from the sides of the erupting right deciduous maxillary first molar (fig.1). A diagnosis of eruption cyst was made. Eruption cyst usually present as solitary swelling on the alveolar ridge mucosa. The treatment of the intact eruption cyst will be surgical excision and exposure of the unerupted primary teeth. In our case, eruption cyst is ruptured and wait and watch instruction was given and in the next follow-up, cyst was disappeared and the tooth was seen erupting normally.


Undiagnosed gastrointestinal bleeding may originate in the small bowel. This presents a diagnostic challenge despite the advancement in contemporary imaging. We report two cases which highlight the limitations of routine investigation for obscure gastrointestinal bleeding.Patient A presented with a history of rectal bleeding, treated with interventional embolisation of caecal angiodysplasia. A diagnosis of neuroendocrine tumour (NET) was reached two years after presentation following intraoperative right hemicolectomy resection of a presumed recurrent angiodysplastic bleed. Patient B presented with recurrent melaena labelled as non-steroidal anti-inflammatory drug (NSAID) induced gastritis. After multiple endoscopic and radiological investigations, a 4.5 cm mass was visualised on imaging after three years, which was histologically proven as gastrointestinal stromal tumour (GIST) of the small bowel. Both patients experienced a delayed diagnosis despite multiple investigations and careful follow-up.Our case series discusses the benefits and limitations of investigation for gastrointestinal bleeding and suggests a need for continued multidisciplinary input in situations where the patient presumed diagnosis remains in question.OGIB remains a diagnostic challenge and is attributable to small bowel pathology in 75% of cases. This suggests a need for continued investigation in situations where the patient presents multiple times despite adequate treatment for the presumed underlying condition. His past medical history was significant for coronary artery bypass graft, atrial fibrillation, non-insulin dependent diabetes mellitus, chronic obstructive pulmonary disease and hypercholesterolaemia. He was not taking anticoagulants. He presented on four separate occasions from May to December 2015 and was investigated with multiple gastroscopy and colonoscopy, which were negative. Computed tomography of abdomen and pelvis (CT AP) highlighted widespread lymphadenopathy involving the mesenteric, retrocrural, retroperitoneal, iliac chain and inguinal regions. MRI of the small bowel was unremarkable. VCE was also non-contributory. In May 2017, he underwent a DBE which demonstrated caecal angiodysplasia, treated by interventional embolization of the ileocaecal branch.(RCC) and medical optimisation, he was transferred for definitive haemorrhage control. At laparotomy, an annular stricturing mass 60 cm proximal to the ileocaecal junction with associated lymphadenopathy at the root of the mesentery was demonstrated. Oncologic right hemicolectomy with side-to-side primary anastomosis was performed. Histology demonstrated a Grade 1 well differentiated neuroendocrine tumour (NET) of the ileum (T4N1M0) with mitoses of <2/10 HPF, proliferative index by Ki67 of <2% and clear resection margins.In June 2017, he presented to the Emergency Department with ongoing rectal bleeding. On examination, he was haemodynamically stable, but pale and tachypnoeic with no signs of an acute abdomen. Urgent haematological investigations were significant for haemoglobin of 5.4 g/dL with an associated acute kidney injury . After transfusion of four units of red cell concentrate 3Patient B, a 66 year old gentleman, presented to Gastroenterology outpatient services in September 2013 with long standing iron deficiency anaemia (IDA) and multiple episodes of melaena. This was initially investigated with gastroscopy, colonoscopy and CT AP which were negative for pathology.In June 2016, the patient returned to the Gastroenterology outpatient clinic complaining of right sided abdominal pain, anorexia, malaise, altered bowel habit, unintentional weight loss and night sweats. Repeat gastroscopy and colonoscopy revealed antral gastritis deemed secondary to non-steroidal anti-inflammatory (NSAID) use for arthralgia. Iron studies confirmed iron deficiency anaemia . NSAIDs were discontinued and an oral proton pump inhibitor (PPI) commenced. Repeat imaging (CT AP) for ongoing IDA in January 2017 see , Fig. 2 Ultrasound guided biopsy revealed spindle cell tumour with fascicular growth pattern, strongly positive for vimentin and C-kit and 20% positive for Ki67, confirming a diagnosis of gastrointestinal stromal tumour. In April 2018, he underwent laparoscopy, small bowel resection and primary anastomosis. Postoperative histological analysis demonstrated a 5 cm C-Kit (CD117) positive, spindle cell type gastrointestinal stromal tumour (GIST).4Obscure GI bleeding (OGIB) is defined as overt or occult bleeding that persists after initial negative endoscopic examination . Five peBritish Society of Gastroenterology (BSG)  and AmerA meta-analysis by Pasha et al  demonstrDespite extensive evaluation, Patient A and Patient B received delayed diagnoses of small bowel neoplasm. Both VCE and DBE have limitations in their diagnostic value. VCE is operator-dependent and does not confirm histological diagnosis, with a rate of capsule retention of 1.2% . DBE serOur case highlighted variability in the diagnosis of NET presenting with OGIB. Hernandez et al. reported small bowel NET causing OGIB, later diagnosed using DBE . Dutta eRomero-Espinosa et al. described 5 cases of small intestinal GIST presenting with OGIB, concluding that CT imaging and angiography remains the main tool for diagnosis . Patient5OGIB remains a diagnostic challenge with small bowel pathology present in 75% of cases. Both patients experienced delayed diagnosis despite multiple investigations and careful follow-up. This suggests the need for continuous investigation where patients present recurrently despite adequate treatment for the initial diagnosis. NETs and GISTs are distinct in pathology and represent uncommon but important causes of gastrointestinal bleeding. Clinicians should consider unusual causes of gastrointestinal bleeding when the clinical picture is unconvincing.None.None.Study is exempt from ethical approval.Written informed consent was obtained from the patients 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.Jia Wei Teh, Amy L. Fowler, Noel E. Donlon, Waqar Khan, Iqbal Z. Khan, Michael Waldron, and Kevin Barry contributed to data acquisition, analysis, interpretation and drafting the case series.Research Registry - researchregistry4719.Jia Wei Teh.Not commissioned, externally peer-reviewed.


Dumbbell spinal cord tumors are infrequent pathologic entities. The optimal approach to safe surgical resection is ill-defined and must often be individualized. This is assisted with multiple tumor classification systems. Here, we describe a novel technique used to safely and successfully resect a large thoracic dumbbell schwannoma originating from the left T3 spinal nerve root with extension into the posterior mediastinum adjacent to the parietal pleura and thoracic aorta. A review of the literature was performed to study described surgical approaches to primary spinal dumbbell tumors. The decision-making process and preoperative imaging for operative planning are included. A detailed description of the procedure follows with intraoperative images. Gross total resection with no neurologic sequelae was achieved. Previously described operative techniques for resection of primary spinal dumbbell tumors with advantages and limitations of each are then reviewed. Gross total resection was safely achieved utilizing a single-staged posterior retropleural approach with anterior thoracoscopic guidance. The tumor was removed en bloc through a large posterior window. The prone position was utilized for the entire case with no intraoperative repositioning required. No intraoperative or immediate postoperative complications occurred. We report a novel approach to resecting a large primary spinal dumbbell tumor. A single-stage retropleural approach with anterior thoracoscopic guidance facilitated safe and successful gross total resection. Maintenance of the prone position throughout surgery allowed for reduced operative time, excellent anterior, and posterior visualization and no added patient morbidity. Repositioning to the lateral decubitus position may not be required in select cases.  Primary spinal tumors (PST) are relatively uncommon, accounting for approximately 15% of central nervous system (CNS) tumors . Their cA 57-year-old woman presented with three months of progressively worsening intrascapular pain extending to the left lower thorax, lower extremity weakness, numbness, and gait disturbance. Thoracic computed tomography (CT) and magnetic resonance imaging (MRI) were obtained demonstrating a large mass originating from the left T3 neural foramen, with extension into the posterior mediastinum and invasion into the entire T3 pedicle, much of the T3 vertebral body, and the ipsilateral T2/3 and T3/4 facet joints Figure -1D.There was also invasion into the superior aspect of the T4 pedicle Figure -2C.The mass caused profound compression upon the spinal cord. Extraspinal tumor dimensions were 42 mm x 68 mm x 49 mm, and intraspinal tumor dimensions were 10 mm x 10 mm. Preoperative CT core-guided biopsy was consistent with a schwannoma. Surgical options were discussed due to worsening neurological deficit, and the decision was made to proceed with surgical resection. A CT 3D reconstruction of the thorax was obtained for surgical planning Figure -3D.The patient was positioned prone and the left hemi-thorax was also included in the operative field in anticipation of thoracoscopy. The patient was prepared and draped in an appropriate fashion to allow both vertebral manipulation and thoracoscopy without changing patient position during the operation. A midline incision was made in the posterior cervical-thoracic region, and standard subperiosteal dissection was undertaken to expose the posterior elements. The left T2-4 ribs were also exposed, as they would need to be taken down in an effort to gain access to the posterior mediastinal component of the tumor Figure .We felt that the patient would require supplemental spinal instrumentation due to the anticipation of iatrogenic instability after the tumor resection, in addition to pre-existing cervical kyphosis ,5.A laminectomy was then performed from T2-4 to gain access to the intraspinal component of the tumor Figure . The lefNext, we defined the plane between the undersurface of the ribs and the endothoracic fascia from T2-4 on the left. An ultrasonic bone cutter was utilized to resect approximately 4 cm of the ribs after disarticulating them from the costo-transverse joint. This maneuver allowed us to gain access to the retropleural space Figure . The posThe thoracic surgeons gained intrathoracic access to visualize the tumor from the mediastinum and assist with expression of the tumor posteriorly under direct thoracoscopic guidance Figure . NotablyUpon inspection of the subpleural capsule space, there was no evidence of any residual tumor. A 28-French chest tube was placed in the initial port site and guided posteriorly towards the apex. At that point in time, dual lung ventilation was resumed.Cervical-thoracic instrumentation was then completed after titanium rods were contoured and placed, in addition to allograft. A sub-fascial drain was placed and the site was closed in the usual fashion. Postoperative imaging revealed complete tumor removal Figure -5D.Optimization of spinal alignment was confirmed Figure .After several weeks of inpatient rehabilitation, the patient’s gait function began steadily improving. At her 10-month follow-up, imaging has continued to reveal no tumor recurrence, and good alignment in the sagittal plane with continued neurological improvements. The surgical approach to thoracic dumbbell tumors is complex and should be individualized -10. VariHere, we describe a case of a large schwannoma originating from the left T3 spinal nerve root with extension into the posterior mediastinum adjacent to the parietal pleura and thoracic aorta, with ipsilateral vertebral body, pedicle, and facet joint destruction. This tumor was classified as Eden Type III and Toyama Type IIB. Resection was planned utilizing a single-staged, posterior retropleural approach utilizing anterior thoracoscopic guidance in the prone position. Complete tumor resection was achieved, in addition to optimized spinal alignment. It is accepted that a single posterior approach is effective for resecting tumors with a predominantly intraspinal component . A posteSingle-Stage Posterior-Only Approach A single-stage posterior approach involving laminectomy, constotransversectomy, facetectomy, and sometimes pediculectomy typically ipsilateral to the tumor at has been reported in the literature with success in achieving good surgical outcomes ,9-11. NoAdvantages to the single-stage posterior approach may include limited muscle damage, blood loss, operative time, and postoperative pain . AdditioSingle Stage Anterior Only ApproachSinge-stage anterior-only approaches have been described for Eden type IV dumbbell tumors with significant foraminal and paravertebral extension. Both thoracotomy and video-assisted thoracoscopic surgery (VATS) have been utilized with success . Wang etSingle-Stage Combined Posteroanterior Approach with Video-Assisted Thoracoscopic SurgeryCombined posterior laminectomy and VATS has been introduced as an alternative method to remove thoracic dumbbell tumors ,12,13,15A combined approach offers many advantages for resection of dumbbell tumors as evidenced by our experience. Anterior approaches allow for less posterior bone removal as the extent of tumor visualization required posteriorly is much less . This maSimilar success has been reported in the literature utilizing a combined approach with VATS. Konno et al. reported a series of three dumbbell tumors and two paraspinal tumors of the thoracic spine resected with a combined approach, in the cases of dumbbell tumors, or VATS alone in the cases of paraspinal tumors. GTR was achieved in all five patients . Ohya etPatient Positioning For Combined Posteroanterior Approach With Video-Assisted Thoracoscopic SurgeryRepositioning of patients to the lateral decubitus position may not be required to perform a posteroanterior approach to dumbbell tumor resection. Utilizing a combined posteroanterior approach commonly involves performing a two-step operation where patient positioning must be changed. The posterior approach is often completed with the patient prone, while the anterior VATS is often completed in the lateral decubitus position to allow adequate intrathoracic visualization and exposure of the anterior chest wall ,15. PatiAfter extensive planning with the help of thoracic surgery, we elected to leave the patient prone to both the anterior and posterior steps of tumor resection. To facilitate this, the left upper extremity was not taped down and the field was manipulated to expose the left anterior chest wall, allowing for adequate VATS access to the thorax without changing patient position or requiring preceding posterior closure. Additionally, prone positioning allowed for maintenance of vertebral column alignment through all stages of the operation and minimized opportunity for damage to proximal structures. This helped safely reduce operative time while allowing excellent and convenient visualization of tumor resection from anterior and posterior perspectives. We report a case of large dumbbell schwannoma of the left T3 nerve root with extension into the posterior mediastinum adjacent to the parietal pleura and thoracic aorta . A single-stage extended posterior retropleural approach with anterior thoracoscopic guidance was used to achieve a GTR with optimized results. The authors advocate that a single-stage combined approach with posterior tumor dissection and anterior thoracoscopic visualization for improved safety and delicate steps of anterior dissection may be effective to achieve GTR in appropriate patients. Avoiding repositioning by maintaining the prone position may safely shorten operative time, allow excellent visualization of both the anterior and posterior operative fields simultaneously, and add no additional patient morbidity in select cases.


Primary central nervous system lymphoma is a rare, malignant non-Hodgkin lymphoma that can arise in the brain, spinal cord, eye, leptomeninges, or cranial nerves. Primary central nervous system lymphoma is rare, accounting for 2–6% of all primary brain neoplasms and 1–2% of all non-Hodgkin lymphomas, and it usually presents as a solitary lesion. Cerebellar involvement is present in only 9% of cases. We present an unusual case of primary central nervous system lymphoma presenting as multiple lesions in the cerebellum in an immunocompetent host.A 71-year-old Caucasian man presented to our hospital with acute onset of dizziness, nausea, vomiting, and gait imbalance. Contrast-enhanced computed tomography revealed three intensely enhancing masses in the right cerebellar hemisphere. Whole-body positron emission tomography and computed tomography failed to demonstrate a primary tumor of origin outside the central nervous system. The patient underwent right suboccipital craniotomy with partial resection of the visible tumor from the right cerebellum. Histopathology revealed diffuse large B-cell lymphoma, non-germinal center type.Primary central nervous system lymphoma is rare, even more so in the cerebellum. However, the overall incidence of primary central nervous system lymphoma is rising in both immunocompromised and immunocompetent patients. The highly aggressive nature of primary central nervous system lymphoma necessitates timely diagnosis and intervention. In this report, we review the available literature for a better understanding of the pathophysiology and management of primary central nervous system lymphoma. To the best of our knowledge, this is the first reported case of a patient with primary central nervous system lymphoma presenting with multiple masses in the cerebellum. Primary central nervous system lymphoma (PCNSL) is a rare, malignant non-Hodgkin lymphoma (NHL) that is confined to the central nervous system. Most cases are diffuse large B-cell lymphoma. PCNSL is an aggressive tumor that extensively invades the parenchyma but by definition remains confined within the central nervous system (stage IE) , 2. PCNSPCNSL presents as a solitary lesion in 60–70% of patients, most commonly in the hemispheres (38%), thalami/basal ganglia (16%), corpus callosum 14%), periventricular regions (12%), and rarely in the cerebellum (9%) [%, periveA 71-year-old Caucasian man presented to the emergency department of our hospital with a 1-week history of abrupt-onset blurry vision, dizziness, nausea, vomiting, and ataxia initially thought consistent with a posterior circulation stroke. The patient denied associated vertigo or headache. He had no prior history of stroke and had been taking prophylactic aspirin for years for a patent foramen ovale. Noncontrast head computed tomography (CT) performed in the emergency department demonstrated no visible masses or hemorrhage. A shrapnel adjacent to the patient’s eyes precluded the possibility of further visualization with magnetic resonance imaging (MRI). He was admitted for further workup and treatment. Carotid Doppler ultrasound showed no stenosis. Subsequent CT angiography did not clearly visualize the brain parenchyma but showed no vascular compromise. The initial working diagnosis was of a cerebellar stroke, and the patient was transferred to the acute inpatient stroke rehabilitation service.Despite participation in rehabilitation therapies, his symptoms progressively worsened, prompting repeat noncontrast head CT 9 days after admission, which demonstrated indistinct, masslike lesions in the cerebellum, one with evidence of hemorrhage and surrounding vasogenic edema and mild hydrocephalus. Contrast-enhanced CT performed later that day revealed three intensely enhancing masses in the right cerebellar hemisphere Fig. . The patBone marrow biopsy and testicular ultrasound demonstrated no evidence of lymphoma in these sites. The result of human immunodeficiency virus (HIV) testing was negative. The patient elected to pursue induction chemotherapy. Because of his age, the radiation oncology service recommended against whole-body irradiation to minimize neurotoxicity. The patient was started on the MATRix regimen , which the patient has tolerated well thus far, with no residual disease seen on contrast-enhanced head CT scans. The patient has experienced marked improvement in his symptoms with treatment and is able to ambulate with a walker, but he still reports balance problems and blurry vision.PCNSL is a malignant NHL. It was first described by Bailey in 1929 as perivascular sarcoma . The vasThe location of the PCNSL determines the clinical picture. The most common presentation, seen in 70% of patients, is focal neurological symptoms. Forty percent present with neuropsychiatric symptoms, followed in frequency by signs of increased intracranial pressure such as headache, nausea, and vomiting in 33%, seizure in 14%, and ocular symptoms in 4% of cases . DetermiPCNSL usually presents as a single homogeneous mass with surrounding edema; therefore, a wide differential diagnosis must be considered because many malignant and benign lesions present with a similar radiographic pattern. Malignant lesions that can appear similar include glioblastoma multiforme (GBM) and brain metastasis from primary cancers such as prostate and lung adenocarcinomas. Although histologically high-grade gliomas such as GBM have a greater degree of cellular and nuclear pleomorphism, infiltrative borders, and central necrosis with pseudopalisading, radiologically they can be difficult to distinguish from PCNSL because both can cross the corpus callosum (“butterfly pattern”)  and can Benign lesions with radiographic appearance similar to PCNSL include subacute infarction, demyelinating diseases, infectious lesions, and neurosarcoidosis. Rich macrophage infiltrates seen on biopsy may point toward infarction or demyelination. Demyelinating disorders are characterized by axonal sparing, whereas infarcts show axonal loss. One particularly important infectious etiology to consider is toxoplasmosis, which is the most common brain lesion in patients with HIV. Distinguishing features include greater diffusion on DWI and clinical improvement with pyrimethamine-sulfadiazine can help establish a diagnosis of toxoplasmosis . NeurosaThe clinical picture of PCSNL can also mimic posterior circulation stroke presentation, as did our patient. Therefore, this condition must be excluded, keeping in mind that it represents nearly 20% of all ischemic strokes. A posterior circulation stroke is defined as infarction of the vertebrobasilar arterial system . The undMany conditions can mimic posterior circulation ischemic stroke. Acute peripheral vestibular dysfunction is much more common and typically causes vertigo only with no other neurological symptoms. A head impulse test or Dix-Hallpike maneuver may aid in diagnosis. Acute intracranial hemorrhage, subarachnoid hemorrhage, and tumors may also mimic posterior stroke, which can be distinguished using proper imaging. Moreover, basilar migraine with aura should always be excluded, as well as other metabolic disturbances, such as hypoglycemia or central pontine myelinolysis, which can initially present with stroke-like features. Sarcoidosis or Whipple and Behçet disease can present acutely but with preceding systemic clinical features. Antibody-associated disorders such as Miller Fisher syndrome  should be excluded as well .Unfortunately, PCNSL is an aggressive tumor with high rates of recurrence after treatment. It has a poor prognosis without treatment, with an expected survival of only 3–6 months. Chemotherapy alone or combined with radiation can boost the estimated survival time up to 25–60 months . RelapseThe combination of chemotherapy and radiation is the standard treatment and can markedly improve the poor survival rates. High-dose methotrexate combined with whole-brain radiation has been widely used . The prePCNSL is a rare disease with an increasing incidence in both immunocompromised and immunocompetent individuals. Our patient, who had multiple lesions in the cerebellum, highlights two unusual presentations of this rare disease that made the initial diagnosis particularly challenging. Because imaging in this disease is nondiagnostic, biopsy is crucial to differentiating PCNSL from malignant and benign lesions that present in a similar manner and appear similar on imaging. The highly aggressive nature of PCNSL necessitates timely diagnosis and intervention. Therefore, physicians must include this disease in their differential diagnosis of mass lesions found in the central nervous system.


Glomuvenous malformations are congenital, benign, vascular malformations classified as subtypes of glomus tumors with predominant blood vessels, usually present at birth or childhood with multiple, bluish, soft papules and nodules or plaque-like cutaneous lesions. Later present with pronounced segmental lesions, superimposed on the primary lesions, suggesting type 2 segmental mosaicism. We present a rare case of familial glomuvenous malformations, a healthy young female presented with multiple bluish papules since birth which later developed dissemination later in her adolescence. Moreover, her father also had similar skin lesions on his left lower back. Glomuvenous malformations (GVMs) or previously termed glomangiomas are congenital, benign, vascular malformations, classified as a histological subtype of glomus tumors with predominant blood vessels , 2.Glomus tumors are benign tumors or hamartomas of the perivascular structure, arise from modified smooth muscle cells, called glomus cells, located in the walls of the Sucquet-Hoyer canal, a specialized arteriovenous anastomosis central to thermoregulation , 2.There are two forms of glomus tumor, solitary variant (90% of the cases) and multiple variant 10%) , while t0% , whilGlomuvenous malformations usually present at birth as multiple, bluish, less than 1 cm in diameter, soft papules and nodules or plaque-like cutaneous lesions that are typically painful on compression. They slowly grow in size and number with age, involving in dermis and subcutis, with hyperkeratotic and cobblestone appearance, affecting predominantly extremities.α-smooth muscle actin and negatively for desmin [Histologically, GVMs appear as distended vein-like malformed vascular channels surrounded by one or more layers of glomus cells; uniform blue cuboidal cells with plump nuclei and eosinophilic cytoplasm . These gr desmin .A 20-year-old Thai female from Chonburi, presented with multiple bluish papules on left thigh since birth. She noticed some new lesions later developed on her right lower back ten years ago. The lesions were asymptomatic until the last 2 months, they became painful on palpation . She wasPhysical examination revealed multiple discrete soft, noncompressible painful bluish papules and nodules on her right lower back and left inner thigh. She denied episodes of bleeding from the cutaneous lesions or gastrointestinal tract.Computed tomography angiography (CTA) of lower abdomen and left thigh revealed multiple discrete small cutaneous and subcutaneous enhancing nodules at the anteromedial aspect of left upper thigh, size up to 1 cm, and no evidence of vascular malformations. The excisional skin biopsy was done on her left thigh and sent for pathology. Histological examination revealed large dilated, blood-filled vascular channels, surrounded by layers of glomus cells in the dermis .Laboratory tests revealed normal complete blood count and coagulation. Her blood chemistry tests are otherwise within normal limits.After the diagnosis was made, the prognosis and treatment options were informed to the patient. She does not have a cosmetic concern and seeks no further treatment.Glomuvenous malformations (GVMs) mostly present since infancy or childhood without gender predilection , multiplGVMs are caused by loss of function mutations in the glomulin gene  which encodes glomulin protein ; a compoSome patients with familial or congenital multiple GVMs may later present with pronounced segmental lesions, arranged in a flag-like pattern, superimposed on the ordinary, non-segmental phenotype, suggesting type 2 segmental mosaicism (T2SM). Like our case, we present an otherwise healthy young female presented with GMV lesions since birth which later developed dissemination later in her adolescence. There have been less than 15 cases of congenital multiple GVM with type 2 segmental manifestation reported to date , 11.In the past, GVM was considered a subtype of venous malformations (VMs) but recently proposed as a distinct entity according to its different clinical characteristic, histopathological findings, prognosis and treatment responses. Other clinical differential diagnosis includes blue rubber bleb nevus syndrome, Mafucci syndrome and congenital plaque-like blue nevi , 5. WhilVenous malformations (VM) are compressible, bluish lesions that affect deeper tissue. They shrink when externally compressed or subjected to an antigravitational posture. Phleboliths and stasis can be associated with pain. Unlike GVMs, which are less compressible and painful under compression. D-dimer elevation can also be found more commonly in VM . MagnetiBlue rubber bleb nevus syndrome (BRBNS) is a rare congenital disorder associated with double (cis) somatic activating TEK mutations , 16, 17,IDH1 (NADP(+)-dependent isocitrate dehydrogenase 1 gene) has been identified, with the same mutation found in enchondromas and spindle cell hemangiomas [Mafucci syndrome is an extremely rare, sporadic, and nonhereditary disease characterized by multiple enchondromas and subcutaneous hemangio-endotheliomas localized on extremities especially on fingers and toes . These langiomas , 16, 18.The goals of treatment in GVMs are mainly aesthetic considerations, pain relief, functional improvement and prevention of complications. Current treatment options include surgical excision, sclerotherapy, and laser.Unlike VM, GVMs, especially plaque-type, responded poorly to sclerotherapy or embolization. Surgical excision is less appropriate due to their extensive and multifocal nature, additionally, it could result in disfiguring scars and demonstrated 10% of recurrence rate .Many case reports and studies demonstrated satisfying efficacy using laser treatments on GVM lesions. Dual-wavelength Pulsed Dye Laser and Neodynium-doped Yttrium Aluminium Garnet laser (PDL-Nd:YAG) showed the most promising results in 60% of size reduction and improvement in color with safety profile , the youThe mechanism of its effectiveness is that the laser system provides deeper penetration of the tissue to the lesions of GVMs, of which affect both the dermis and hypodermis. PDL allows greater absorption of the Nd:YAG laser due to the production of methemoglobin via hemoglobin, requiring less fluencies of the latter and therefore a decreased risk of adverse effects . Focal G


Many different diseases present as cavitary pulmonary nodules. The spectrum of diseases ranges from acute to chronic infections, chronic systemic diseases, and malignancies. To decide on the most likely or correct diagnosis may be challenging. Knowledge of common and uncommon radiological findings in correlation with relevant clinical history and findings is necessary to make the right diagnosis and recommend the correct follow-up or step forward. The aim of this pictorial review is to present a brief overview of CT findings of common cavitary lung diseases seen in adult patients. A cavity is defined in the Fleischner glossary as “a gas-filled space, seen as a lucency or low-attenuation area, within pulmonary consolidation, a mass, or a nodule” . The cavThe content of the cavities is of little help in differentiating benign and malignant lesions. A benign bronchogenic cyst may contain fluid levels, as may a bronchoalveolar carcinoma. The degree of contrast enhancement in the content of nodules (< 10 HU) is shown to indicate benign lesions and may be used to distinguish aspergillomas from lung cancer 5. Rim enThe acute onset of symptoms is sometimes helpful to distinguish malignant and nonmalignant disease, but a benign infection may, for instance, cause hemoptysis when affecting a nearby vessel. Benign diseases may also cause fatigue and weight loss similar to malignancies. Acute onset of fever is usually helpful to distinguish benign disorders from malignancies, but a pulmonary cancer may present with a superinfection secondary to the tumor . HoweverStreptococcus p., Staph.aureus, Klebsiella p., H. influenzae); typical and atypical mycobacterium; fungi ; and parasites . 22. 2122]Cavitating nodular opacities in the course of rheumatic diseases are much rarer than interstitial pulmonary pneumonias and vasculitides. The nodules occur when epithelial cells cover a necrotic area, creating a necrobiotic nodule, which is the cause of the cavity. These are most often located in the periphery or subpleurally. They may vary in size and wall thickness. Normally, they are asymptomatic and resolve without specific treatment, but cough and hemoptysis have been reported in some cases Figure  23]..23].Sarcoidosis is a rare differential diagnosis of pulmonary cavitary nodules. Less than 1 per cent of patients with sarcoidosis develop cavitary nodules. They are reported as rounded or oval-shaped and are usually found in the perihilar or peripheral areas .The most commonly encountered solitary cavitary nodule in the lung is a malignant tumor . They maPulmonary metastasis from squamous cell carcinomas, mainly from the gastrointestinal tract and breast, sarcomas, and adenocarcinomas frequently cavitate Figure  26]. On. On26]. Langerhans cell histiocytosis (LCH), lymphangioleiomyomatosis (LAM), lymphocytic interstitial pneumonia (LIP), and findings of pneumocystis jirovecii infection are all cystic lung diseases Figures , 25–26. 27282930To summarize, cavitary pulmonary lesions are caused by a number of varying disease entities. Paying close attention to disease-specific CT findings combined with the clinical history and findings are important tools leading to the correct diagnosis.


Despite the rich vascularization of the penis and its close proximity to other pelvic organs, cutaneous manifestations of metastatic disease to the penis are an uncommon occurrence. Penile lesions suspected for malignancy should alert clinicians to differentiate between primary and secondary tumors. While the majority of metastatic malignancies arise from the genitourinary tract, we present a unique case report of a 51-year-old male with penile metastasis of primary rectal adenocarcinoma. A thorough diagnostic evaluation was performed including imaging studies, colonoscopy, as well as penile biopsies with associated immunohistochemistry panel. The patient was diagnosed with penile metastases secondary to invasive rectal adenocarcinoma. Due to the aggressive nature of the patient’s presentation, systemic chemotherapy was initiated for palliative measures as the patient declined any radical surgical intervention.  Cutaneous metastases to the penis and scrotum arising from primary colorectal adenocarcinoma are extremely uncommon. Squamous cell carcinomas are the most common type of primary penile malignancy . PrimaryWe report a case of a 51-year-old Caucasian male who presented to the emergency department with severe groin pain for the past five days. The patient also complained of multiple, painful, subcutaneous nodules to the penile shaft and scrotum. Physical examination demonstrated two well-demarcated, indurated, painful plaques involving the glans of the penis Figure . A markeUltrasound of the testicles showed normal appearance of the testicles with no evidence of any intratesticular mass. Computed tomography of the abdomen and pelvis revealed two rim-enhancing hypodense ovoid shaped lesions in the central and left lateral aspect of the perineum, inferiorly and left laterally adjacent to the root of the penis. Incidentally, it also revealed asymmetric wall thickening of the rectum highly concerning for malignancy Figure , and likStaphylococcus aureus (MRSA) positive, and urine cultures were positive for Enterococcus spp. and MRSA. A penile evacuation and incision and drainage of the abscesses were performed in addition to a replacement of the suprapubic catheter. The patient was discharged from the hospital and currently awaiting reinitiation of his chemotherapy pending clearance from the aforementioned infections.Furthermore, due to the urethral obstruction, a suprapubic catheter was placed. The patient was offered a palliative penectomy due to intractable groin pain but declined. Subsequently, he was referred to outpatient oncology for the initiation of palliative systemic chemotherapy including FOLFOX  and bevacizumab. Also, he was unable to complete a second chemotherapy administration due to a second hospitalization for intractable groin pain and ulceration with purulent drainage from the metastatic nodules, two months after his initial presentation. Wound cultures were methicillin-resistant Despite the rich vascularization of the penis, cutaneous manifestations of metastatic disease to the penis are a rare phenomenon. While the majority of primary malignancies arise from the genitourinary tract, we present a unique case of penile metastasis of primary rectal adenocarcinoma. Routes of metastases are not fully understood, however most authors postulate several pathways: retrograde venous route, retrograde lymphatic route, arterial spread, direct extension, and iatrogenic secondary to instrument implantation -4,6-7. MThe most common chief complaint is malignant priapism -6,11. WiWith cutaneous metastasis to the penis being a rare entity, an astute clinical differential should be thoroughly considered when evaluating penile lesions of unknown etiology. Pre-malignant and primary malignancies , infectious causes , and non-malignant lesions  should be investigated through a targeted history and physical and subsequent diagnostics -4,6. AccThe literature reveals that most patients with penile metastases have widespread disease at the time of presentation -9. The pIn conclusion, cutaneous metastases to the penis from rectal adenocarcinoma are a rare entity, as the majority of secondary cutaneous penile malignancies arise from the genitourinary tract. Despite its paucity, clinicians should approach penile metastases with appropriate diagnostic and therapeutic modalities. It is important to recognize this unusual presentation to initiate timely palliative and supportive care measures.


Azygos vein varix is a very rare disease associated with a risk of rupture or thrombosis. Here, we report a case of azygos vein varix mimicking bronchogenic cysts. A 79‐year‐old female patient presented with abnormal shadows on a chest X‐ray during an annual check‐up. A plain chest computed tomography (CT) showed a well‐defined tumour, approximately 66 X 65 X 45 mm in size, behind the trachea. An enhanced CT scan was refused due to asthma complications. A high signal on T2W1 images from magnetic resonance imaging (MRI) indicated a cystic tumour. Diagnosed as a bronchogenic cyst, a cyst excision was scheduled. Upon observation with a thoracoscope, a dark purple‐red saccular tumour was observed continuing on to the azygos vein and was removed using linear staplers. The patient is alive and well 4 years after the operation. If a cystic tumour located in the right upper mediastinum is observed, the presence of azygos vein varix should be considered. Azygos vein varix is a very rare disease and is mostly asymptomatic. Most cases are detected on chest X‐rays by chance. The disease is operable, and surgery is often performed to avoid rupture or thrombosis. Contrast‐enhanced computed tomography (CT) scans or enhanced magnetic resonance imaging (MRI) scans are useful for the diagnosis. However, in instances where contrast agents are refused due to complications such as asthma, azygos vein varix resembles a mediastinal tumour similar to bronchogenic cysts.A 79‐year‐old female patient presented with abnormal shadows on a chest X‐ray during an annual check‐up. The patient had a history of asthma and skin cancer. There was no history of trauma. Blood tests, including for haematology, renal, and hepatic function, were within normal ranges. There were no abnormal findings on electrocardiograms. A plain chest CT showed a well‐defined tumour approximately 66 X 65 X 45 mm in size behind the trachea. The tumour was homogenous with 45 Hounsfield units (HU) Fig. . CalcifiAzygos vein varix is very rare, and most of the tumours are detected during annual check‐ups without symptoms. Although cases with heart failure, portal hypertension, and obstruction of the inferior vena cava have been reported, considering its occurrence in a young patient Contrast‐enhanced CT and enhanced MRI scans are useful for the diagnostic procedure. However, our patient suffered from asthma. Therefore, enhanced CT and enhanced MRI scans could not be performed. Without the enhanced imaging, the tumour resembled bronchogenic cysts or foregut duplication cysts. Previous reports have shown that preoperative diagnoses include bronchogenic cysts, neurogenic tumours, and swollen lymph nodes A previous report describes a case where the tumour did not change in size for 4 years, and surgery was not performed If cystic tumours located in the right upper mediastinum are observed, the presence of azygos vein varix should be considered.Appropriate written informed consent was obtained for publication of this case report and accompanying images.


Abdominal hiccups are often masked by abdominal epilepsy (AE) in clinical settings. Spontaneous arrhythmic muscular movements sometimes raise the suspicion for abdominal myoclonus as well. AE is an atypical and rare cause of seizure disorder. It is a manifestation of different transient abdominal complaints correlating with abnormal electroencephalogram (EEG) changes and adequate response to anti-epileptic drugs. We present a case of an 80-year-old female who presented with an episode of tonic-clonic seizure that lasted for almost 10 minutes. The patient was confused and had a facial droop. She had another episode of seizure with a perseverative speech followed by left facial drooping and left upper extremity weakness. She continued having fluctuating mental status and left-sided hemiparesis with intermittent abdominal twitching. She was getting more bradykinetic than bradyphrenic. The computed tomography (CT) scan of the head and magnetic resonance imaging (MRI) of the brain showed a parietal lobe mass that was confirmed on biopsy as malignant glioma. The long-term video monitoring EEG report showed the occurrence of persistent right parietal spikes with background slowing. The brain mass was later treated with radiation therapy and surgery. Abdominal epilepsy (AE) is an uncommon and undocumented cause of parietal lobe tumor in the literature. It is characterized by diverse abdominal complaints, electroencephalogram (EEG) abnormalities, and favorable response to anti-epileptic drugs. Often, the abdominal epileptiform movements are masked by abdominal hiccups. Focal epilepsy with generalization can present with diversified patterns . We present a case of an 80-year-old female with a history of left breast cancer status post-lumpectomy who presented with an episode of a tonic-clonic seizure that lasted for 10 minutes. In the past, she had an early-stage hormone receptor (HR)-positive/ human epidermal growth factor receptor 2 (HER2)-negative that was treated with surgery followed by radiation. During hospitalization, she had another episode of seizure with a perseverative speech followed by left facial droop and left upper extremity weakness. She continued having fluctuating mental status with left-sided hemiparesis and intermittent abdominal twitching. During this epileptic episode, which lasted over five minutes, there was no involvement of the face, arm, or leg. She did not lose consciousness but was getting more bradykinetic than bradyphrenic, with left-sided body weakness. It looked like a hiccup initially but had the spontaneous rhythmic movements localized to the abdomen. Clinically, it appeared likely to be an epileptic event with atypical features. Complete blood count and metabolic workup were unremarkable. Computed tomography (CT) scan of the head and magnetic resonance imaging (MRI) of the brain showed a right parietal lobe mass with an estimated size of 3.9 x 2.1 x 3 cm with surrounding vasogenic edema  once a day, fosphenytoin 1,300 mg IV once a day, and dexamethasone 4 mg IV once a day followed by levetiracetam 500 mg oral tablet twice a day to prevent further episodes of seizures. She had been taking anastrozole 1 mg oral daily tablet after left breast lumpectomy. The craniotomy was done to remove the lesion, followed by stereotactic radiation. Later, the result of a brain biopsy confirmed it as malignant glioma. However, her abdominal epileptic episodes were controlled after increasing the dose of levetiracetam to 750 mg twice a day.AE is a rare seizure disorder of episodic gastrointestinal manifestations with ECG abnormalities. The diagnosis of AE is a challenge, and its prevalence is unclear . In a smThe key to diagnosing AE is a high clinical suspicion with the abnormal abdominal movements and a concurrent ECG irregularity. AE responds successfully to a single or double anti-epileptic agent. Kraimer et al. reported a case of a 16-year-old male with symptoms from two years of age, consisting of abdominal pain and distension lasting for several hours resolving spontaneously with rare epileptiform discharges over the right frontal region . The seiAE has been frequently misdiagnosed as abdominal hiccups in clinical settings and should be correlated with EEG findings to rule out any epileptogenic event. This emphasizes the need for medical personnel to consider AE in a clinical context with an underlying malignant brain lesion.


Ten years old girl was referred to our consultation for a tumefaction of the right buttock, it was soft consistency and mobile in relation to the deep planes (A). Magnetic resonance imaging reveals a large fatty lobulated mass well encapsulated with septa with low signal T1/T2 (B). Pathological examination of the resection piece confirmed the diagnosis of lipoblastoma (C). Lipoblastoma is a rare benign pediatric tumor derived from embryonic fat. It is often morphologically indistinguishable from primitive myxoid mesenchymal tumor of infancy. Translocations affecting the 8q11-13 region are commonly reported with lipoblastoma and proper diagnosis requires cytogenetic analysis to distinguish it from malignant myxoid liposarcoma. It is important to consider lipoblastoma in the diagnosis of a rapidly enlarging fatty mass in children. Complete resection is the only definitive treatment and should not be delayed when impingement on surrounding structures is imminent.