Fetal abdomino-pelvic cystic lesions are uncommon and can have varied etio-pathogenesis. Most commonly they originate from the gastrointestinal or genitourinary tract. These include choledochal cyst, hydronephrosis, renal cyst, mesenteric/omental cyst, ovarian cyst, meconium pseudocyst, and hydrocolpos/hydrometrocolpos among others. Fetal hydrometrocolpos is rare with a reported incidence of 0.006% and its diagnosis requires a high index of suspicion. Antenatal ultrasound and magnetic resonance imaging (MRI) is invaluable in diagnostic evaluation. This case report describes the imaging features of antenatally detected congenital hydrometrocolpos with Mullerian duplication secondary to cloacal malformation using antenatal ultrasound and MRI. Per-operative findings and other possible differential diagnoses are discussed along with a brief review of literature. Most of these lesions are incidentally detected during routine antenatal ultrasound examination. Fetal hydrometrocolpos is rare with a reported incidence of 0.006%, diagnosis of which requires a high index of suspicion. Careful scrutiny of the morphology of lesion, its location, and relationship with normal structures aids in suggesting the appropriate differential diagnoses, and in some cases may even reveal the exact diagnosis. Fetal magnetic resonance imaging (MRI) is invaluable in confirming the ultrasound findings and improving the diagnostic accuracy.Fetal abdomino-pelvic cystic lesions are uncommon and can have varied etio-pathogenesis. Most commonly they originate from the gastrointestinal or genitourinary tract. These include choledochal cyst, hydronephrosis, renal cyst, mesenteric/omental cyst, ovarian cyst, meconium pseudocyst and hydrocolpos/hydrometrocolpos among others.A 27-year-old primigravida with non-consanguineous marriage presented to our institution for the first time at 30 weeks of gestation. Anomaly scan done at an outside institution at 21 weeks reported a distended urinary bladder with upstream hydronephrosis. The patient’s antepartum history was normal. There was no significant previous medical and surgical history. She was referred for routine ultrasound evaluation. Maternal aneuploidy markers were normal.Trans-abdominal ultrasound scan was performed using GE LogiqS8 ultrasound machine. A single live intrauterine pregnancy was discovered. The placenta was anterior and not low-lying with adequate amniotic fluid index. Two-vessel umbilical cord was seen. Upon scanning the fetal abdomen, there was a large central elongated midline cystic lesion of size 3.9 × 4.5 cm with a 5-mm-thick midline septum and fine internal echoes . This cyT1-weighted images along with sagittal, coronal, and axial T2-weighted images of the fetus were acquired. A T1 hypointense and T2 hyperintense cystic mass was identified between the bladder and rectum with a vertical T2 hypointense midline septum  for further investigations.The neonate was passing urine and meconium through a single opening. Physical examination revealed clitoral hypertrophy (2 cm) and single opening in the vestibule with absent anal and vaginal opening. Upon inserting the feeding tube through the opening in vestibule, there was a common channel of length 5 mm, beyond which two openings were identified: anterior opening was common for urethra and vagina and a posterior opening for rectum. Karyotyping revealed 46 XX type. No other systemic abnormalities were detected upon screening for VACTERL association.At one week of age, the baby underwent exploratory laparotomy. Per-operative findings revealed dilated and hypertrophied bladder reaching till the umbilicus. Posterior to the bladder, dilated vagina was present which had a vertical septum with two hemi-uteri on top of it. There was pus discharge from left fallopian tube with multiple flimsy adhesions between the bowel loops. Thus, the final diagnosis was cloacal malformation with longitudinal vaginal septum and uterus didelphys. Division of the vaginal septum was done, tube vaginostomy was performed and a catheter was placed in the right hemivagina. Transverse divided colostomy and surface vesicostomy was also performed. The baby was discharged in a stable condition and definitive surgery was planned in the subsequent follow-up visits. Most frequently, it is discovered as an incidental abdomino-pelvic cystic lesion during routine antenatal ultrasound evaluation in late second or third trimester. Owing to secretion of fluid by secretory glands in the cervix and vagina under the influence of maternal hormones, these get collected in the obstructed vagina which then gets distended and presents as a cystic mass; alternately vaginal distension can occur due to collection of urine due to presence of urogenital sinus or cloacal malformation.Fetal hydrocolpos is a rather rare condition having an estimated incidence of 0.006% . However, urogenital sinus and cloacal malformation may also result in hydrocolpos.Obstructive causes of hydrocolpos which impede the drainage of vaginal secretions include imperforate hymen, distal vaginal agenesis, and transverse vaginal septum. The most common cause has been stated to be imperforate hymen. Consequently, there is a confluence of the lower urinary tract, the female reproductive tract, and the rectum into a common channel which exteriorizes via a single perineal opening. In urogenital sinus, the urethra and vagina form a common channel of variable length which opens through a single perineal orifice along with a separate opening for the anus.During embryogenesis, the cloaca appears as the terminal part of the hindgut and forms a common recess for the urogenital and anorectal tract in the fifth week. The urorectal septum extends caudally and partitions the cloaca into two separate channels  during the sixth and seventh weeks. Upon contact with the inferiorly growing urorectal septum, the cloacal membrane ruptures resulting in the creation of two orifices. The urogenital sinus undergoes further differentiation and forms the urinary bladder and urethra, along with a part of the vagina in females. Cloacal malformation ensues if the urorectal septum fails to join the cloacal membrane during this period. Cloacal malformations have been divided into two clinical groups based on the length of the common channel, which dictates surgical management. A common channel less than 3 cm in length is associated with a lower incidence of other related abnormalities and a comparatively simpler surgical reconstruction. On the other hand, a common channel greater than 3 cm in length is linked with a higher incidence of associated anomalies, difficult surgical repair, and poorer functional results. Another classification categorizes cloacal malformation into three subtypes depending on the length of common channel and urethra: (a) Type 1 (common channel length<1 cm), (b) Type 2 ; and (c) Type 3 cloaca (common channel length>3 cm or urethra<1.5 cm).Cloacal abnormalities can present as a spectrum of malformations, including cloacal dysgenesis, classic cloaca, posterior cloaca, urogenital sinus, cloacal variant and posterior cloacal variant, each with its own characteristic features.In around 40% of patients with cloacal malformation, there is associated Mullerian duplication comprising two hemiuteri and two hemivaginas separated by an intervening septum. This septum can be partial/total and symmetric/asymmetric. Two major complications may stem from hydrocolpos: (a) it may exert compression on the trigone of bladder, producing vesico-ureteric reflux, megaureter, and hydronephrosis; and (b) the hydrocolpos may get secondarily infected, if left undrained, resulting in pyocolpos. Reflux of fluid/secretions into the peritoneal cavity by way of fallopian tubes can cause fetal ascites and later on lead to development of endometriosis, pelvic adhesions, and infertility.There are many characteristic ultrasound imaging features which can help in diagnosis. Hydrocolpos is seen as a midline elongated pear-shaped retrovesical pelvic/abdomino-pelvic cystic mass, often displacing and compressing the bladder against the anterior abdominal wall. A potential source of diagnostic error is misidentification of hydrocolpos as distended bladder. Recurrent distension and emptying at different scan times helps confirm that it is urinary bladder; additionally, identification of umbilical arteries on its either side is also helpful in identifying the bladder. Hydrocolpos, on the other hand, has an elongated shape and shows funneling inferiorly toward the pelvis. At the superior aspect of the hydrocolpos, one may visualize the imprint of cervix and identify the uterus, which itself may contain fluid, although the presence of uterine musculature results in far lesser uterine distension as compared to vagina. Furthermore, the presence of a midline septum within the cyst goes in favor of hydrocolpos. These features, along with urinary tract dilatation due to mass effect and fetal ascites secondary to escape of urine and secretions into the peritoneal cavity by way of fallopian tubes, are highly suggestive of underlying cloacal malformation.T1-weighted images extending into the perineum and the absence of rectal dilatation. However, it turned out to be classic cloacal malformation. In classic cloaca, one would expect a high position of the recto-sigmoid cul-de-sac due to agenesis of the distal bowel segment, along with dilated colon. We posit that the extremely short length of common channel (5 mm) in our case as confirmed on post-natal examination may be responsible for the visualization of meconium-filled non-dilated rectum extending into the perineum. Presumably, with increase in the length of common channel, the typical findings of classic cloaca i.e. absent rectal meconium and colonic dilatation will predominate.In our case, based on antenatal ultrasound and MRI, possibility of urogenital sinus was favored over classic cloaca due to visualization of meconium-filled rectum on  Hydrometrocolpos may also be seen in association with such syndromes as McKusick Kaufman syndrome , Bardet–Biedl syndrome , Mayer–Rokitansky–Küster–Hauser syndrome  and OHVIRA /Herlyn–Werner–Wunderlich syndrome.There are several other findings that may be present in association with cloacal malformations such as oligohydramnios , polyhydramnios [in cases with esophageal atresia with VACTERL  association], lumbo-sacral spinal abnormalities , non-visualization of the anus and ambiguous genitalia.Other differentials of cystic abdominal masses to be considered include ovarian cyst, intestinal duplication cyst, meconium cyst, etc.; however, imaging features such as location on either side of urinary bladder, presence of gut signature, identification of echogenic calcified wall, respectively, can help in differentiation with these entities.The management of cloacal anomalies is primarily surgical. Initial surgery aims to decompress the vagina, perform urinary diversion, and create a temporary colostomy. This is followed by definitive surgical repair (depending on the length of common channel) to reconstruct the anatomy, with the aim to achieve bowel and urinary continence along with normal sexual function.Congenital hydrometrocolpos with Mullerian duplication is a rare anomaly. Radiologist should be familiar with the characteristic ultrasound imaging findings as they can be the first to suggest the diagnosis of an underlying cloacal malformation. With the help of a careful ultrasound evaluation, diagnosis can be made with good certainty. Fetal MRI helps provide detailed assessment of pelvic anatomy rendering it valuable in confirmation of diagnosis and as a problem-solving tool. Early diagnosis with prompt referral and management in dedicated neonatology/pediatric surgery neonatal ICU is essential to prevent complications and ensure good quality of life for the patient.Congenital hydrometrocolpos with Mullerian duplication is a rare entity and should be included in the differential diagnosis of antenatal abdomino-pelvic cystic mass.It is important not to mistake distended vagina for urinary bladder.Ultrasound and MR imaging features are fairly characteristic to allow an accurate diagnosis, so radiologists should be familiar with the imaging features so as to initiate appropriate post-natal management.


Beaver tail liver is a rare hepatic anatomical variant in which the left hepatic lobe extends into the left upper quadrant and surrounds the spleen. This extension of the left hepatic lobe consists of normal hepatic parenchyma with no functional liver impairment. In trauma cases, however, the extended left hepatic lobe is vulnerable to injury and confused for a splenic injury due to similar echogenicities and densities on ultrasound and CT. It is also misdiagnosed as a splenic subcapsular hematoma, perisplenic hemorrhage, or mass. Usually, the beaver tail liver is encountered incidentally in patients. We present a 67-year-old male with a history of chronic obstructive lung disease, coronary artery disease, myocardial infarction, and aortic valve replacement. The patient was admitted for further evaluation and placed under the Baker Act for attempting to overdose on oxycodone to commit suicide. Initial imaging identified an ill-defined lesion on CT angiography, which raised concerns for potential malignancy of the liver. Ultimately, an MRI of the abdomen ruled out a malignant lesion due to a lack of abnormal contrast enhancement over the circumscribed region. Consequently, further imaging of the liver led to the incidental discovery of the beaver tail liver in this patient. Due to the rarity of this variant, available literature regarding beaver tail liver is limited to several case reports describing it as an incidental finding. This case highlights the rare nature and unique challenges the beaver tail liver presents for emergency medicine physicians, surgeons, and radiologists interpreting imaging studies without knowledge of its existence. It is important to emphasize how the unexpected presence of the left hepatic lobe in the upper left quadrant of the abdomen can lead to misinterpretations in FAST (focused assessment with sonography in trauma) exams and CT scans. Using non-invasive tools, such as color Doppler, is one way to reduce the incorrect diagnosis of hepatic anatomic variants.  Beaver tail liver is a rare hepatic anatomical variant in which the left hepatic lobe extends into the left upper quadrant and surrounds the spleen . The extThe patient is a 67-year-old male with a past medical history of cirrhosis, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), myocardial infarction, and aortic valve replacement. The patient arrived via emergency medical services at Wellington Regional Medical Center after he experienced a syncopal event and was found unconscious with pinpoint pupils at home. After the patient regained consciousness, he admitted to consuming ten 30 milligram tablets of oxycodone due to depression and an attempt to commit suicide. On initial exam, the patient was awake and alert after receiving Narcan en route and at the emergency department (ED). On admission, the patient presented with a heart rate of 107 beats per minute, blood pressure of 156/69 mmHg, and respiration rate of 23 breaths per minute. The urine drug screen was only positive for cannabinoids. The patient was placed under the Baker Act, also known as the Florida Mental Health Act, which led to involuntary hospitalization for examination, provision of crisis services for mental illness, and prevention of self-harm.Initially, abdominal ultrasound demonstrated a fatty liver, splenomegaly, and status post cholecystectomy. Next, CT angiography of the chest revealed an ill-defined 5.1 x 4.6 cm lesion in segment IV of the liver and splenomegaly. Alpha-fetoprotein tumor marker test was a normal level of 1.4 ng/ml. Further imaging was performed to rule out malignancy. CT of the abdomen showed partial right hepatectomy and a non-enhancing, rounded soft-tissue lesion with peripheral fat attenuation posterior to the hepatic surgical staple line thought to represent focal fat necrosis. Finally, an MRI of the abdomen confirmed a zone of fat necrosis or fatty degeneration over an oval-shaped, circumscribed 3.5 cm region at the surgical site with no abnormal contrast enhancement to suggest a mass lesion. With no mass visualized, interventional radiology did not perform a biopsy. But, additional imaging of the liver led to the incidental discovery of the beaver tail liver Figures -3. The pAn anatomic variant of the liver is an atypical finding. Hepatic variants include accessory lobes, which are contiguous with the main portion of the liver and consist of normal liver parenchyma . MeanwhiIn the setting of suspected trauma to the liver or spleen, a routine focused assessment with sonography in trauma (FAST) can be misinterpreted by the unexpected presence of the left hepatic lobe in the left posterior subphrenic space ,4. The eOn CT scans, the Hounsfield Unit (HU) attenuation of the liver is typically greater than that of the spleen. On average, the spleen measures approximately 40-60 HU while a non-pathological liver measures between 50 and 65 HU ,5. HowevTo reduce incorrect diagnoses, color Doppler can be utilized as a non-invasive tool to differentiate between hepatic anatomic variants and the spleen . Color DBeaver tail liver is a rare hepatic anatomic variant that presents with an extension of the left hepatic lobe contacting or wrapping around the spleen. Anatomical variants of the liver, such as the beaver tail liver, can present challenges for emergency medicine physicians, surgeons, and radiologists interpreting imaging studies without knowledge of their existence. Practitioners need to be aware of different methods of differentiating between the liver and the spleen organs to reduce false-positive results on FAST exams and CT scans along with confusion about the anatomy. The elongated left lobe of the liver can be missed if the physician is unfamiliar with its presence and does not actively search for it. It is important to consider hepatic anatomic variants during patient examinations and utilize, for example, different transducer angles during FAST exams and color Doppler to distinguish between the liver and the spleen.


Spontaneous hematoma of the iliopsoas is a rare pathological circumstance; in the majority of cases published in the literature, it is associated with disorders of hemostasis due to anticoagulant treatment or coagulopathies. We present a case of a 64-year-old man on acenocoumarol, an anticoagulant of the vitamin K antagonist family, for atrial fibrillation, who presented with a severe left hip and flank pain with a huge ecchymosis on the left flank and a partial inability to extend the left thigh. A CT scan confirmed the diagnosis of iliopsoas hematoma. Given the hemodynamic stability of the patient, he benefited from a conservative treatment with a favourable evolution. This case highlights the underlying conditions, diagnosis, and treatment of this uncommon complication. Spontaneous iliopsoas hematoma is a rare disease that is part of the pathological processes affecting this deep anatomical compartment . It is oWe present the case of a 64-year-old man on acenocoumarol for atrial fibrillation who was treated for this complication. The underlying conditions, diagnosis, and treatment of this uncommon situation are briefly discussed.A 64-year-old man presented to the emergency department of our hospital for severe left hip and flank pain persisting for 5 days in the absence of a traumatic context or previous surgery. The patient had a medical history of atrial fibrillation and taking acenocoumarol 4 mg 1/2 tablet daily for 5 years.Physical examination revealed mucocutaneous pallor with a huge ecchymosis on the left flank Figure  and tendAn abdominal CT scan revealed a left iliopsoas hematoma measuring approximately 9 × 10 × 18 cm Figure .In addition to the acenocoumarol suspension, the patient was transfused with 5 units of red blood cells and was closely monitored.The CT scan was repeated one week later and no expansion of the hematoma was observed; anticoagulation was restarted.Clinical follow-up at 1 month showed complete resorption of the ecchymosis along with the resumption of normal physical activity Figure .The iliopsoas muscle, enveloped by its fascia, is an extraperitoneal compartment that contains the psoas major, psoas minor, and medial iliacus, which are the major flexors of the thigh and trunk . SpontanSpontaneous iliopsoas hematoma (SIPH) usually occurs in the context of anticoagulation, coagulopathies, and hemodialysis . SeveralAcenocoumarol, reported in our case, is an anticoagulant of the vitamin K antagonist (VKA) family and is extensively administered in the treatment and prophylaxis of a variety of diseases including atrial fibrillation, pulmonary embolism, and valvular heart disease. It is still widely used because of its low cost in many healthcare systems. The incidence of bleeding events associated with it has been estimated in a report series to be 5.1%, dominated by gastrointestinal and cerebral haemorrhage . The intThe clinical manifestations of SIPH are nonspecific, such as ecchymosis or flank and possibly abdominal pain that radiates to the inguinal region. Neurological signs secondary to compression of the femoral nerve by the hematoma are of variable intensity, such as paresthesia or weakness of the extension of the thigh and leg . ImagingTherapeutic management depends on the time of diagnosis and the haemodynamic status. If the diagnosis is early and the patient is stable, as in our case, treatment can be conservative, with the suspension of the anticoagulant, administration of an antidote in case of overdose, transfusion therapy, and appropriate analgesic treatment . EmbolizPersistent hemorrhage is an independent risk factor for short-term mortality requiring monitoring of hemoglobin levels and repeat CT scans in follow-up .Acenocoumarol is a conventional anticoagulant that is still widely prescribed in many countries but has a high risk of serious bleeding complications, mainly in the case of overdose.Spontaneous iliopsoas haematoma is an exceptional complication of its administration, if undetected, it can lead to disabling neurological sequelae with permanent lower limb extension deficit, or even be life-threatening in the presence of haemodynamic instability and persistent active bleeding.


BMP1 and BMP4; connective tissue development, COL3A1 and COL5A3; cilia morphogenesis and function, DNAH5 and MAPK15; as well as hormonal homeostasis, ESR1. Direct involvement of BMP1 both in male sexual development and hernia genesis makes it a strong candidate for linking the two pathologies, PSW and multiple hernias, observed in the present case. Yet the presence of a group of mutated genes linked to myopathies  and muscular dystrophy (ITGA7) raises a question about the involvement of these muscular pathologies in hernia genesis and unsuccessful hernia repairs associated with the current case. During a routine anatomical dissection of an 81-year-old male cadaver received through the Gift Body Program of Saint Louis University School of Medicine (SLU SOM), a massive bulging in the abdominal area was observed that was consistent with numerous hernia repairs noted in the donor’s self-reported medical history. Gross anatomical dissection of the cadaveric body revealed extensive herniation of portions of the small intestine and peritoneal sac along the costal margin and extending to the left aspect of the abdomen. Additionally, an uncircumcised phallus was buried within the suprapubic fat pad and demonstrated simple, grade III penoscrotal webbing (PSW), creating an impression of micropenis presence. To gain additional insights into the current case, analysis of the coding regions (exomes) of DNA procured from the body for putative genetic variants was performed using next-generation sequencing (NGS) technology. This analysis revealed 110 rare  ≤ 0.01), pathologic/deleterious genetic mutations. The most relevant variants to this case were the ones associated with male sexual development,  Male sexual development occurs under the intricate control of many genes. Mutations involving these specific genes that play a role in male sexual development can result in genitalia malformations. The condition of penoscrotal webbing (PSW) has been discussed under a variety of names, including webbed penis, penoscrotal fusion, penoscrotal pterygium, and penis palmatus . PSW is The anatomical organization of male external genitalia emerges during embryonic and fetal development, and understanding the developmental biology of external genitalia is critical for appreciating pathologies that lead to malformations of the penis and surgical repair of such malformations . The exaA classification system of PSW has been proposed by El-Koutby et al. and is the most used method in describing this condition and for planning surgical correction. This classification system first divides the condition into the primary and secondary webbed penis . The priA thorough review of the literature regarding PSW, hernias, and genetic variants linked to such pathologies revealed no previous reports of the co-occurrence of PSW and extensive hernias. Though the normal penoscrotal relationship is suggested to have a genetic basis, the literature lacks reports that support this claim . Given tThis article was previously presented as a meeting abstract at the 2023 Anatomy Connect AAA Annual Scientific Meeting on March 25, 2023.Anatomical characterizationThe body of an 81-year-old male was received through the Gift Body Program of Saint Louis University School of Medicine (SLU SOM) with a signed informed consent of the donor. The self-reported medical history indicated at least seven hernia repairs, quadruple bypass heart surgery, irritable bowel syndrome, diverticulitis, and hypertension. This individual did have children, but it is not known if these children were biological. An external examination of the cadaver from the sternal angle to the feet was conducted. The upper limbs, neck, and head of this cadaver were absent as they were utilized elsewhere for surgical training purposes. Numerous scars were observed on the abdomen including a large midline scar in addition to a large bulge to the left aspect of the abdomen Figure . AnotherThe phallus was uncircumcised Figure  with a pAnatomical dissection of the abdomen revealed extensive herniation of the small intestine within the peritoneal sac Figure . These hAs removal of the skin continued inferiorly towards the region of the pubic symphysis, a large loop of small intestine was located within the suprapubic fat pad Figure .We believe that the presence of this hernia in addition to a large amount of suprapubic fat obscured the length of the shaft of the penis giving it a much smaller appearance than was present.3 compared to the mean volume of 12-30 cm3 in normal males [The anterior abdominal wall was removed and hernias that were incarcerated in the anterior abdominal wall were carefully freed. The entirety of the bowel was examined and revealed multiple stitches on the small intestine suggesting previous surgical procedures. Evidence of a left femoral hernia repair, including sutures and mesh, were observed and appeared to compress the left spermatic cord. The spermatic cord was dissected to reveal a normal ductus deferens that was traced into the pelvic cavity. Once in the pelvic cavity, the following structures were identified: ampulla of ductus deferens, seminal vesicles, ureters, prostate, urethra, and the related vasculature. The prostate was also intact and was located inferior to the bladder. All internal genital organs appeared normal. The testes were palpated within the scrotum to ensure that two were present, descended into the scrotum, and were of normal size measuring to be approximately 15.3 cmal males ,7.Lastly, a dissection of the perineum was conducted. A flap of tissue that appeared to be the scrotal septum was observed fusing the entire ventral length of the penile shaft to the scrotum Figure .Dissection of the scrotum revealed the uncircumcised phallus was buried within the suprapubic fat pad and accompanied by a simple, grade III PSW. All other male anatomical structures were observed to be normal.Genetic screenGiven the uniqueness of this case of extensive abdominal hernias and penoscrotal webbing, a screen for the putative genetic variants was performed using next-generation sequencing (NGS) on the Illumina platform. The exome sequencing of DNA extracted from the embalmed cadaveric tissue revealed 110 rare  ≤ 0.01), pathologic/deleterious genetic variants  signaling pathway has been identified as a key regulator during initiation of morphologic differentiation of the genital tubercle and its outgrowth [SHH signaling leads to the upregulation of BMP4, HOXA13, and HOXD13, which would work to provide a delicate balance between apoptosis and proliferation. This balance is necessary for the proper differentiation of the genital tubercle and its dysregulation can result in abnormalities involving genital tubercle elongation and the spatiotemporal balance between apoptosis and proliferation [The results presented in this case support clinical observations pointing toward PSW being polygenic in nature and provide important insights into its etiology. Indeed, the respective genetic screen identified mutations in four genes that could be closely linked to the development of human external genitalia: R1 Table . There autgrowth . The differation .DNAH5 and MAPK15 are involved in the formation and maintenance of cilia, including the primary cilia [SHH [FGF receptor [WNT signaling pathways [SHH, FGF, and WNT signaling. This, along with the mutation in BMP4, which might negatively affect its proapoptotic function, could disrupt a dynamic equilibrium between cell proliferation and apoptosis [ESR1 at the penoscrotal junction is suggested to play a role in the etiology of penile webbing [ESR1 in this individual supports this notion.ry cilia ,11, whiclia [SHH , FGF recreceptor , and WNTpathways . Therefopoptosis , thereby webbing . The detCOL3A1 have also been linked to both hiatal hernias and bilateral inguinal hernias [COL5A3, a gene coding for type V collagen in addition to bilateral inguinal hernia repair [BMP1 have also been found to have large umbilical hernias [Second, the present case is unique because there have been no previous reports of an individual with PSW also displaying such extensive abdominal hernias. PSW is considered to fit within the spectrum of penoscrotal transposition (PST) . Dependi hernias ,23. Patia repair , which w hernias . With PSCOL3A1, COL5A3, and BMP1. COL3A1 encodes collagen type III alpha 1 chain while COL5A3 encodes type V collagen, which is found in tissues containing type I collagen and regulates the assembly of heterotypic fibers composed of both type I and type V collagen. Because an aberrant collagen I to collagen III ratio can compromise skin repair and make it more vulnerable to wound recurrence, it is possible that these COL3A1 and COL5A3 mutations are responsible for the extensiveness of the incisional hernias in this individual. Also, given the importance of the extracellular matrix (ECM) in wound repair, the reported mutation in BMP1 is also of significant interest. Indeed, mutations in this gene have been reported to result in impaired production of type I collagen, which in this case would also compromise the integrity of the ECM [Third, the current case is unique because of the presence of numerous hernia repairs that resulted in extensive incisional hernias, primarily due to an aberrant wound-healing process. The latter is supported by the detected mutations in three genes:  the ECM .ITGA7, NRAP, POLM, SCN5A, XIRP2) and muscular dystrophy (ITGA7) (Table Fourth, the presence of a group of mutated genes linked to myopathies (BMP1 both in male sexual development and hernia genesis makes it a strong candidate for linking the two pathologies together, PSW and multiple hernias, observed in the present case.The increasing trend in the incidence of genital malformations and the decline in human male reproductive health have attracted much concern in recent years. Though the knowledge of the impact that genetics has on the development of external and internal genitalia has improved in recent decades, the exact genetic underpinning is yet to be identified. However, direct involvement of In summary, the current case has a high clinical and educational value because it not only describes the co-existence of two unique anatomical abnormalities, PSW and multiple hernias, but also provides important insights into their potential common genetic underpinnings.


Synovial sarcoma, originating from mesenchymal cells, represents a rare and aggressive sarcoma subtype.This case report describes a rare occurrence of synovial sarcoma in the soft palate, with only a few cases described in the literature.A 38-year-old male presented with a painless mass on the soft palate, which raised suspicion of an abscess and emphasized the importance of considering malignancy in persistent or progressive soft tissue masses, even in atypical anatomical locations. The diagnostic workup, including imaging modalities such as maxillofacial computed tomography (CT) scan, magnetic resonance imaging (MRI), and positron emission tomography-fluorodeoxyglucose (PET-FDG) scan, played a crucial role in confirming the diagnosis and assessing disease extension. The standard treatment is the complete excision of the tumor. Nevertheless, when it comes to tumors located in the head and neck region, defining standardized margins proves to be a challenge. Radiotherapy can play an important role, particularly in those with tumors larger than 5 cm or positive margins. While chemotherapy offers certain advantages, its application remains a subject of controversy despite its potential benefits.Timely referral and multidisciplinary management are essential in optimizing patient outcomes. Although synovial sarcoma poses diagnostic and therapeutic challenges, advances in diagnostic techniques and personalized medicine offer hope for improved outcomes. Originating from mesenchymal cells, sarcomas represent a rare and heterogeneous group of malignant tumors. They account for less than 1% of all adult cancers . The mosAlthough most cases of sarcoma lack a clearly defined etiology, several associated or predisposing factors have been identified. Alongside well-known genetic predisposition syndromes like Li-Fraumeni syndrome and neurofibromatoses type I, there is a growing recognition that a significant proportion of sarcoma patients may carry pathogenic germline variants. Other predisposing factors include retinoblastoma, exposure to radiation therapy, chemotherapy, chemical carcinogens, chronic irritation, lymphedema, as well as the involvement of human immunodeficiency virus (HIV) and human herpes virus 8 in the pathogenesis of Kaposi sarcoma . LifestyTypically, sarcoma presents as a painless, gradually growing soft tissue tumor in young adults . In rareThe differential diagnosis includes benign soft tissue tumors, such as lipoma, as well as malignant tumors, such as sarcoma, metastatic carcinoma, melanoma, or lymphoma. The United Kingdom Department of Health has published criteria for soft tissue lesions that deserve an urgent referral: a soft tissue mass with a diameter superior to 5 cm, a painful lump, a lump that is increasing in size, a lump of any size that is deep to the muscle fascia, or recurrence of a lump after previous excision .In terms of treatment, further investigation is necessary. The standard treatment is the complete excision of the tumor; however, there are no standard margins defined for head and neck sarcomas. Radiotherapy can also play an important role in the treatment, especially in the postoperative treatment when the patient presents with positive or marginal margins or tumors larger than 5 cm. Nevertheless, the radiation dose is not yet standardized . RegardiThis clinical case, due to the rarity of oropharyngeal synovial sarcoma, evident in its scarcity in medical literature, emphasizes a crucial point: the necessity to alert clinicians about its unique clinical presentation, diagnostic challenges, and the urgency of early referral. This rarity underscores the need for heightened clinical suspicion, timely assessment, and appropriate management, all of which can profoundly impact patient outcomes and survival rates. 2. Due to its presentation as a bulging of the posterior soft palate with mild inflammatory signs, at that time, it was interpreted as a peritonsillar abscess. The patient received treatment with Amoxicillin + Clavulanic acid (875 mg + 125 mg) every 12 hours for eight days, in addition to topical  and systemic anti-inflammatory (ibuprofen 600 mg twice a day for five days) medications.A 38-year-old male presented to his family doctor in August 2022, with a painless mass on the right side of the soft palate, with three weeks of evolution. He worked as a constructor and did not have any relevant medical history, regular medication, allergies, or history of smoking and drinking habits. He had no fever or any other associated symptoms. On physical examination, the mass was approximately 1 cm in diameter when observed, with intact mucosa, mild signs of inflammation, and a soft consistency upon palpation. The patient was apyretic, had a blood pressure of 133/81 mmHg, a heart rate of 82 bpm, and a body mass index of 22 kg/mA follow-up appointment was scheduled for reevaluation a week later. Due to the lack of improvement, an increase in the size of the lesion, and new complaints of intermittent dyspnea and odynophagia within five days, he was referred to the local hospital's emergency department on that day Figure .At the emergency department, blood tests showed no significant changes and a maxillofacial CT scan revealed a large expansive lesion centered on the right palatine tonsil, well-circumscribed, hypodense, and heterogeneously enhancing, measuring approximately 39 mm in maximum diameter. The possibility of a granuloma mimicking an abscess should be considered by clinical and laboratory data. The alternative of a tumor should only be considered based on objective observation. Nodular formations with a diameter of less than 10 mm, with a hypodense central component, were also present in both superior internal jugular chains, which were likely to be adenitis. These are likely to be adenitis, although reactive lymph nodes with typical bilateral central hilum coexist. No other significant pathological changes were observed Figures -3 Due toFollowing the initial assessment by the ORL department, surgical excision was scheduled for three weeks later, at the end of September.Two months after the first appointment, in October 2022, after the partial surgical excision, during a follow-up ORL appointment, it was observed that the mass had increased in size. At this time, it had breached the barrier of the soft palate, had a considerably more suspicious appearance, was covered with fibrin, and had a vegetative aspect. The patient was then treated with tramadol, metoclopramide, and metronidazole, and magnetic resonance imaging (MRI) and positron emission tomography-fluorodeoxyglucose (PET-FDG) scans were requested. Four days later, the patient returned to the emergency department due to further enlargement of the mass. On physical examination, a lesion occupying the soft palate was observed, covered with fibrin, with a vegetative appearance, extending beyond the midline and touching the tongue Figure . It did In mid-October, the pathology results revealed Synovial Sarcoma of Biphasic Subtype (FNCLCC score 3). The patient underwent a PET-FDG scan, which suggested active malignant neoplasm. Bilateral superior lateral cervical lymph node formations, with short-axis measurements in the subcentimeter range, some showing very slight uptake, making it impossible to exclude the possibility of being lymph node lesions. Additionally, a CT-SPN scan report stated: "Compared to the previous maxillofacial CT scan, there is an increase in the size of the known expansive formation centered on the right/paramedian right aspect of the soft palate, currently extending to the uvula, which appears edematous and expanded. (...) Conclusion: Given the histological result of synovial sarcoma, the staging is considered T3 N0."The patient was then referred to the Portuguese Oncology Institute for consultation with the sarcoma group. The patient underwent neoadjuvant chemotherapy, starting at the end of October 2022. After five cycles of chemotherapy, in March 2023, the patient underwent surgery with a right paramedian mandibulotomy approach, extensive resection with conservative cervical lymph node dissection (levels I to III on the right side), and reconstruction using a free left forearm flap.Currently, in July 2023, the patient has been proposed for adjuvant radiotherapy due to the findings on the pathology report, which revealed a synovial sarcoma with unclear margins.Synovial sarcoma is a rare and aggressive subtype of sarcoma originating from mesenchymal cells ,10. WhilThe patient's initial presentation featured a painless mass on the posterior soft palate, initially raising suspicion of a peritonsillar abscess due to the short duration of symptoms, mild inflammatory signs, and the absence of constitutional symptoms. While symptoms like odynophagia are often associated with peritonsillar abscess, their absence is not definitive . As repoThis highlights the importance of considering malignancy in the differential diagnosis of persistent or progressive soft tissue masses, even in atypical locations.In terms of treatment, in the present case, after the histological confirmation of diagnosis, the patient underwent five cycles of chemotherapy followed by surgery with extensive resection and conservative cervical lymph node dissection. As the surgical histological report revealed positive margins, adjuvant radiotherapy was proposed. In the literature, the standard treatment is the complete excision of the tumor with radiotherapy playing an important role in the presence of positive or marginal margins . NeverthAs family doctors, maintaining an astute awareness of uncommon differential diagnoses is paramount in identifying and referring patients to specialized care promptly. This is particularly evident in the presented case, where the patient's medical history did not overtly suggest a predisposition to synovial sarcoma. However, exploring potential underlying genetic predispositions or environmental exposures that could contribute to sarcoma development remains essential.The diagnostic journey was significantly aided by advanced imaging modalities such as maxillofacial CT scan, MRI, and PET-FDG scans. These imaging techniques played a pivotal role in characterizing the lesion, gauging its extent, and evaluating the potential presence of metastatic disease . Swift rPatient-centered care is a core commitment for family doctors, enabling comprehensive and seamless management. Longitudinal follow-up fosters reassessment and early detection of changes. This approach aligns with holistic patient needs, ensuring continuous monitoring.The profound impact of heightened awareness around synovial sarcoma's varied presentations, including rare sites like the soft palate, is paramount. This awareness revolutionizes patient outcomes through early detection and accurate diagnosis - the cornerstones of effective management. This case underscores how embracing heightened awareness mitigates delays, optimizes care, and improves prognosis in synovial sarcoma cases.By synergizing healthcare provider vigilance, patient-centered care, and a commitment to increased awareness, the medical community can profoundly influence the trajectory of challenging cases like synovial sarcoma, underscoring the potential for positive transformation in patient care and outcomes.We presented a rare case of synovial sarcoma in the soft palate, emphasizing the significance of considering malignancy in the differential diagnosis of soft tissue masses. A multidisciplinary approach is essential to ensure accurate diagnosis and appropriate management, with early recognition and timely intervention playing a critical role in improving patient outcomes.To further enhance our understanding and management of this challenging malignancy, continued research and collaboration are essential.


Linea alba hernias are relatively rare types of hernias. They manifest as small protrusions situated in the linea alba between the umbilicus and xiphoid cartilage. Usually, hernia contents comprise the pre-peritoneal fat, omentum, and gastrointestinal tract. However, very few cases of linea alba hernias involving the hepatic round ligament have been reported, to date.An 80-year-old woman presented with upper abdominal pain and a 1-week history of a mass in the upper midline. Abdominal computed tomography revealed adipose tissue protruding from the abdominal wall contiguous with the hepatic round ligament, suggesting a linea alba hernia. During surgery, the hernial sac content was found to be a mass, which was resected. A linea alba hernia defect measuring 20 mm was repaired using a mesh. Histopathological findings revealed that the mass included mature adipocyte proliferation with broad fibrous septa, which was diagnosed as fibrolipoma of the hepatic round ligament.We report the first case of a linea alba hernia involving fibrolipoma of the hepatic round ligament worldwide and describe the clinical features, diagnosis, and surgical procedure with a literature review. Linea alba hernias are relatively rare hernias with predominance in older adults, particularly female patients. Linea alba hernias have been reported to represent only 3.6% of all hernias in Europe and the United States, with lower incidence in Japan . Further2. She had one previous pregnancy and childbirth.An 80-year-old woman with no history of abdominal surgery visited our hospital because of persistent upper abdominal pain and a 1-week history of a swelling. The patient was 145.7 cm tall and weighed 55.8 kg, resulting in a body mass index (BMI) of 26.3 kg/mPhysical examination revealed an elastic soft bulging mass, 8 cm in diameter, in the midline of the upper abdomen, with a zone of defect along the linea alba, without signs of peritoneal irritation. At the time of the patient’s initial ambulance visit, manual reduction of the intestinal tract was successfully achieved. However, repositioning of some hernia contents was deemed impracticable. Blood tests revealed slightly elevated white blood cell count and decreased renal function due to dehydration. Abdominal computed tomography (CT) showed adipose tissue contiguous with the hepatic round ligament with herniation through the linea alba Fig. A–C.Fig. Since manual reduction of the mass led to symptom improvement, elective surgery was subsequently performed. Following an incision in the skin just above the hernial orifice 20 mm), a mass contiguous with the hepatic round ligament and thickened pre-peritoneal fat surrounding the mass was observed (Fig. 0 mm, a mPathological findings showed that the tumor consisted of mature adipocyte proliferation, with intersecting broad fibrous bands Fig. A. CytoloLinea alba hernias are rare in Japan. Less than 100 cases have been reported since Kumagaya et al. first reported it in 1923 [2. She had a history of a single pregnancy and delivery, without a history of trauma. Intraoperatively, the hernia’s development was considered to be primarily due to the abnormal proliferation of pre-peritoneal adipose tissue and resultant defect in the linea alba, rather than obesity or pregnancy history. Linea alba hernias contain the pre-peritoneal fat, omentum, and small intestine in 30.6% of cases, colon in 11.8%, stomach in 7.1%, and falciform ligament in 2.4% [The patient exhibited mild obesity with a BMI of 26.3 kg/m in 2.4% . To our Linea alba hernias in the upper abdominal region are sometimes classified as epigastric hernias. We searched PubMed using the terms “linea alba hernia”, “epigastric hernia”, “hepatic round ligament, and “fibrolipoma”, and identified no publications with those terms. To our best knowledge, except for our case, we found no cases of fibrolipoma of the hepatic round ligament with herniated content in linea alba hernias.In Japan, there have been nine cases , 6–12 inLaparoscopic surgery necessitated the insertion of at least two ports, with one serving as a camera port. Because the patient was not in the postoperative phase and CT imaging suggested the unlikelihood of presence of multiple hernia sacs, intra-abdominal observation using a laparoscope was deemed superfluous. Single-port laparoscopic surgery in linea alba hernia has become reported in recent years . There aRegarding the use of mesh in abdominal wall hernias, there have been reports of significantly fewer recurrences with the use of mesh than with simple suture closure in cases of small hernia orifices of less than 20 mm . Based oAmong the primary tumors of the hepatic round ligament, there are several reported cases of tumors such as cystic lymphangioma , fibromaIf a tumor of the hepatic round ligament is noted intraoperatively, resection of the hepatic round ligament is considered necessary, and a pathological diagnosis of the specimen is required.Herein, we report the first case of linea alba hernia with fibrolipoma of the hepatic round ligament as the hernia content that was repaired using a mesh. Since tumors of the hepatic round ligament may be malignant, resection involving the hepatic round ligament was considered necessary, and the specimen was pathologically diagnosed.


The clinical symptoms of pigmented villonodular synovitis (PVNS) are usually insidious and non-specific; therefore, delays in diagnosis and treatment are common. Here, we describe a case of a 3-year-old patient presenting with long-term joint swelling to highlight the significance of considering PVNS as a differential diagnosis in children to prevent misdiagnosis and ensure early treatment. After arthroscopic debridement, our patient had a favorable clinical outcome and was free of recurrence. Pigmented villonodular synovitis (PVNS) is a rare, benign proliferative disease of the synovial joint, synovial bursa, and tendon sheath. The incidence rate of PVNS is approximately 1.8–8 cases per million people .The symptoms of PVNS are usually insidious and non-specific. Swelling and pain are the major symptoms, and no specific finding is noted in the initial conventional radiography that is performed. Therefore, the diagnosis is often delayed or confused with hemophilic arthropathy, tuberculosis, juvenile idiopathic arthritis, and other rheumatological and malignant disorders.A 3-year-old girl presented with a history of swelling and pain in the right knee without a history of trauma, for 2 years . The paiA modified multidirectional arthroscopic excision was planned for the patient. MRI showed a tumor-like mass, although the evidence of it being malignant was limited. Therefore, a preoperative biopsy was not performed to avoid overtreatment and clinical inconsequence.A conventional anterolateral and anteromedial arthroscopic approach was adopted. After excising the synovium by using a motorized shaver, a well-defined yellow mass covered by the synovium was observed laterally adjacent to the distal patella . RadiofrThe swollen knee was brought back to shape immediately after arthroscopic synovectomy. The child returned to the clinic 12 months after the surgery. MRI revealed no signs of recurrence . At the PVNS, which is characterized by its capacity to invade the subchondral bone and produce cysts and erosions, is rarely observed in children. It usually presents as swelling and pain in the affected joint . MechaniHowever, the established prognosis factors related to PVNS recurrence is limited. In a multicenter study , a largeThe indication for arthroscopic excision should be considered comprehensively, including factors such as growth pattern and clinical behavior. There are two common types of PVNS with distinct characteristics, namely, rarely recurring localized PVNS and diffuse PVNS with a relatively high recurrence rate . ArthrosRadiotherapy and isotopic synoviorthesis have been used in adults during relapse events or as adjuvant modalities . HoweverIn summary, PVNS is a rare disease that mainly involves the knee, especially among children. Despite its rarity, PVNS should be considered as a differential diagnosis in a child presenting with monoarticular arthritis and no remarkable routine examination finding. To confirm the diagnosis, MRI is useful in terms of prompt diagnosis and determination of the severity of the lesion to ensure a better prognosis. Compared with the commonly used open arthrotomy, arthroscopic excision of the knee PVNS in children might lead to a more favorable outcome.


Liposarcoma is a malignant mesenchymal tumor that most commonly involves the retroperitoneum and lower extremities. However, liposarcoma of esophagus has been rarely reported in the literature.MDM2 gene. The patient was diagnosed as having esophageal well-differentiated liposarcoma and recovered well after the operation.We report a case of a 46-year-old man with complaint of intermittent dysphagia for 6 years, accompanied with paroxysmal vomiting of pedicled tumor to the mouth. Imaging studies showed a huge mixed density lesion in the middle esophageal lumen. Surgical resection of the tumor was performed through an external cervical approach. Microscopically, the tumor was composed of mature adipocytes in normal adipose tissue prominently intersected by sparsely cellular fibrous septa containing atypical, enlarged spindle cells with hyperchromatic nuclei. Immunohistochemically, the tumor cells were positive for Vimentin, S-100, CD34 and MDM2. Besides, fluorescence in situ hybridization (FISH) analysis indicated the presence of amplification involving Esophageal liposarcoma is an extremely rare tumor. Due to the nonspecific clinical manifestation and lack of experience, it is challenging to make a clear diagnosis before operation. Definite diagnosis of esophageal liposarcoma depends on histopathology, immunohistochemistry and molecular analysis. Liposarcoma is one of the common malignant mesenchymal tumors which mostly occurs in the retroperitoneum and lower extremities . HoweverA 46-year-old man with complaint of intermittent dysphagia of unknown origin for 6 years was admitted to our hospital. The patient found that sometimes he could extrude fleshy tissue from the mouth and was able to re-swallow it back by himself. Recently, the patient felt the symptom of dysphagia worsened, accompanied by retrosternal pain and heartburn. The medical history of the patient was not remarkable. No obvious abnormality was found by physical examination and laboratory analysis. Iodine esophagogram revealed a hill-like filling defect at the level of T6-T7  in the esophagus, accompanied by contrast reflux and disordered arrangement of mucosal folds. Contrast-enhanced computed tomography (CT) of the chest revealed a mixed density lesion in the middle esophageal lumen, with an upper and lower diameter of about 19.8 cm and a cross section of about 3.7 cm × 2.2 cm  analysis in our case. The post-operative histopathology combined with immunohistochemistry and molecular analysis confirmed the diagnosis of well-differentiated liposarcoma of esophagus.Liposarcoma is a common malignant soft tissue tumor that mostly involves the retroperitoneum and the deep soft tissues of lower extremities . Howevercificity , 15, 16.MDM2 overexpression and/or amplification can be helpful for the diagnosis of liposarcoma.Esophageal liposarcoma needs to be differentiated from the benign lipoma. Liposarcoma is usually large in size and composed of mature adipose tissue and irregular fibrous septa containing diagnostic atypical hyperchromatic stromal cells and less commonly lipoblasts, which are different from benign lipomas. Cases of well-differentiated liposarcoma may clinically mimic giant fibrovascular polyp , 17. AtyComplete resection with a negative surgical margin is the core curative treatment, which can not only remove the tumor to relieve obstruction, but also achieve the goal of radical cure. Surgical approaches are diverse and include total or subtotal esophagectomy or minimally invasive approaches. With the review of literature, external cervical approach, thoracoscopic esophagotomy or endoscopic approach can be considered for surgery , 18, 19.In conclusion, esophageal liposarcoma is an extremely rare tumor. Due to the nonspecific clinical manifestation and lack of experience, it is challenging to make a clear diagnosis before operation. Definite diagnosis of esophageal liposarcoma depends on histopathology, immunohistochemistry and molecular analysis. Complete surgical resection with a clear margin and a long-term follow-up after operation is essential to improve the prognosis.


Neuroendocrine tumors (NETs) are considered the most frequent tumors that affect the small bowels. Despite diagnostic modalities, the diagnosis of small bowel NETs is not straightforward and poses a high challenge to most physicians, due to poor accessibility to this area and the patient's non-specific presentations.We reported a case of a 60-year-old male patient, who presented with severe postprandial epigastric pain of one-month duration, loss of appetite, and weight loss. Investigations revealed no definite diagnosis. Therefore, exploratory laparoscopy was attempted along with multiple biopsies that led to the diagnosis of small bowel NET.We conclude that NETs require a high index of suspicion in patients with recurrent abdominal pain. Neuroendocrine tumors are slow-growing tumors that could occur in any of the body's organs. The gastrointestinal tract is considered the most vulnerable body site for neuroendocrine tumors, which are the foreground primary malignancy in the small bowel . The incThe symptoms of NETs are related to the tumor site and whether it is functional or not, with the majority being non-functional, leading to no or very few symptoms . The facHerein, we present a case in which a 60-year-old male patient presented with abdominal pain of one-month duration; throughout this duration, many investigations and medical management options were attempted, with neither improvement nor reaching a definite diagnosis. The decision was made to explore the abdomen laparoscopically, an area of suspected abnormality was resected in the small bowel, and biopsies were obtained to have the histopathology final definite diagnosis, which showed a small bowel NET.A 61-year-old male patient with no significant past medical and surgical history was referred to our hospital to continue investigations regarding his vague abdominal pain. The patient's history started 40 days prior to referral when he started to complain of postprandial epigastric abdominal pain that was gradual in onset, 20-30 minutes after each meal, colicky in nature, occasionally radiating to the flanks, with a severity of about 9/10 in some episodes according to his description. The pain was associated with loss of appetite, resulting in a weight loss of about 13 kilograms(kg) during the 40-day period. The patient mentioned a history of food aversion in an attempt to avoid exacerbation of his pain. He denied fever, nausea, vomiting, oral ulcers, odynophagia, dysphagia, changes in bowel movement, jaundice, chest pain, palpitation, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or cough. On admission, a thorough physical examination was unremarkable. Upon further questioning and reviewing the patient's records, his family history revealed that his father had died from lung cancer.He initially sought medical help at an outpatient clinic and was prescribed over-the-counter unknown medications, but his symptoms didn't improve. A Helicobacter pylori (H. pylori) test was ordered from the same clinic when his symptoms didn't improve and returned positive, for which he was given triple therapy for H. pylori . The patient's symptoms didn't improve; accordingly, he was admitted to a governmental hospital one month before the current admission. Abdominal computed tomography (CT) scan without contrast upon admission was done and was unremarkable.Gastroscopy followed and revealed findings of antral ulcer patches and a focal intestinal thickening. A biopsy was taken and showed chronic gastritis. This raised suspicion of untreated H. pylori infection, so treatment was resumed with triple therapy.A few days later, the patient was discharged home. He was readmitted to the same hospital one week later due to increased abdominal pain frequency and severity. Another abdomen and pelvic CT scan with IV contrast showed new findings of ileal segment wall thickening, as well as a moderate amount of pelvic free fluid Figure .Hemorrhoids and two polyps in the transverse and descending colon were seen in a colonoscopy done at the same admission, along with a CT angiogram that was also unremarkable Figure .These investigations were inconclusive, and the need for further studies and a specialized hospital was mandatory. Accordingly, the patient was referred and admitted to our hospital for further evaluation.Laboratory results upon admission are listed in Table The patient’s carcinoembryonic antigen (CEA) was 2.19 ng/ml (reference range = ≤5.2 ng/mL), cancer antigen 19-9 (CA 19-9) was 9.77 (reference range = 0.0-39.0 U/mL), and alfa fetoprotein was 3.9 (reference range = ≤5.8 U/mL).In the subsequent two days, the patient had multiple attacks of exacerbation of his pain, and analgesia was given along with esomeprazole 40 mg bid.He was planned and prepared for small bowel enteroclysis magnetic resonant imaging (MRI) on the third day of admission, which revealed no bowel dilatation, stenosis, focal lesion, or any other findings other than the last CT scan Figure . The patient continued to complain of abdominal pain with an increase in its severity, so the decision was made to go for an exploratory laparoscopy with liver biopsy, omental biopsy, and free fluid aspiration. Intraoperatively, there was a suspicion of ischemia, and the question was if the appeared segment was viable or not, so the decision was to convert to open, in which exploration, the small intestine from the ileocecal valve to the duodenojejunal junction revealed the presence of multiple palpable masses about 1*2 cm each, 35 cm proximally away from the ileocecal valve. There was also an ischemic small bowel segment about 30 cm in length . According to these findings, the decision was to resect about 65 cm from the small bowel  Figure , with siThe patient remains stable postoperatively. Meanwhile, histopathology showed a well-differentiated, grade 1 neuroendocrine tumor invading the muscularis mucosa into the subserosal tissue. All surgical margins were found to be uninvolved by the neoplasm Figure . Lymph iBefore discharge, a staging chest CT scan showed no remarkable findings suggesting metastasis.The patient was then discharged with recommendations of daily dressing over the wound, with instructions regarding follow-up with the oncology clinic. It is worth mentioning that the patient was lost to follow-up.Our patient experienced a 40-day history of abdominal pain. Up to a quarter of the adult population will experience abdominal pain at any one time; most of these episodes resolve spontaneously. Abdominal pain can be acute or chronic, which is defined as lasting three months or longer . There iAs about half of the patients older than 65 years who sought medical advice in the ED for abdominal pain are admitted, and as many as one-third require surgical intervention later on, abdominal pain must be considered serious [Small bowel pain can be caused by motility disturbances and nonobstructing conditions, such as inflammation, ulcers, or neoplasms, which can be aggravated by food ingestion that may cause dull periumbilical or other midline discomforts . PostpraA neuroendocrine tumor is a term used to describe a uniquely wide variety of benign and malignant neoplasm subtypes that are mainly subdivided into poorly differentiated and well-differentiated, each characterized by features specified to the progenitor neuroendocrine cells they originate from. In addition, these cells have the ability to produce hormones and substances specific to each type .NETs that produce active substances are called functional while those that do not are called nonfunctional. Forty percent (40%) of neuroendocrine tumors are found to be hormone producers, thus causing certain symptoms according to the hormone . HoweverAn international survey in 2014 that included 1928 patients with NETs revealed that most patients had delayed diagnosis, and 58% had metastasis at the time of diagnosis. Furthermore, patients reported many physician visits and extensive resources used to reach the diagnosis [In surveillance of the Surveillance, Epidemiology, and End Results (SEER) database of 35,618 patients with NETs, the patients' age of onset was usually the sixth decade with a median of 63 years of age at the time of diagnosis .In this case, the patient's age was 61 years old, and he presented with nonspecific symptoms of recurrent, severe abdominal pain, weight loss, and anorexia, and upon examination, no remarkable findings were found. This led to a delay in his diagnosis and many laboratory tests and imaging were done accordingly.The most affected organs by NETs are the gastrointestinal (GI) tract and the bronchopulmonary systems. The GI tract constitutes what is about 55% of all cases, with the small intestine forming 45% . The incSmall bowel neuroendocrine tumors (SBNETs) are now the most common types of tumors affecting the small intestine, and unlike adenocarcinomas, which mostly affect the duodenum, NETs are most likely to affect the ileum . SmokingClinical symptoms of neuroendocrine tumors in the small bowels depend on their exact site and functionality. Most cases are nonfunctional and result in little to no symptoms in the early stage.SBNETs exhibit symptoms if they metastasize to other organs or lymph nodes . A largeLate in the course, patients could have mass effect symptoms  or metastasis-related symptoms. In metastasis, secreted hormones from the tumors will be able to bypass the portal circulation and so not be eliminated from the body; this will lead to carcinoid syndrome development . The main symptoms of carcinoid syndrome are flushing, diarrhea, abdominal pain, heart valve involvement and possible destruction, edema, respiratory wheezing, and telangiectasia .The patient in this case has been diagnosed with NETs 40 days following a vague abdominal pain. Metastasis and lymph node invasion were excluded with a follow-up CT scan after the diagnosis was made.The SBNET diagnosis is considered challenging, with a high rate of misdiagnosis as a benign condition. This is due to the initially associated symptoms, which are mostly nonspecific as mentioned before, and their inaccessible site, which leads to late diagnosis and possible metastasis at the time of diagnosis. Metastasis at the time of SBNET diagnosis is 30%, and 40% will have lymph node invasion .Diagnosis is achieved by a clinical approach accompanied by laboratory tests  and imaging, but histopathology of the obtained biopsies remains the confirmatory diagnostic method. However, the diagnostic approach should be directed to each case individually.For localization and staging of small bowel NETs, both anatomic and functional imaging modalities are required; ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are examples of anatomic modalities, whereas single-photon emission computed tomography (SPECT) and positron emission tomography (PET) describes functional ones. CT scan sensitivity for primary small bowel NETs ranges from 7% to 38%, but this can be improved to 82% if the presence of mesenteric lymphadenopathy or fibrosis is interpreted as evidence of a small bowel primary tumor .Surgical resection is the standard of care in patients with locoregional disease . SegmentHistopathology retrospectively showed mucosal ischemic changes, as NETs may present with different clinical scenarios. In cases of mesenteric ischemia, the standard approach is CT angiography, which was done in our case and was unremarkable. There is a published case in 2017 of a midgut neuroendocrine tumor presented with acute intestinal ischemia. In that case, the patient complained of nonspecific symptoms for about one year before manifesting with acute mesenteric ischemia, and abdominal X-rays revealed pneumatosis intestinalis and an abdominal ultrasound and computed tomography confirmed the diagnosis. The patient was submitted to a segmental enterectomy .Based on the European Society for Medical Oncology, follow-up investigations should include clinical symptom monitoring, biochemical parameters, and conventional and somatostatin receptor (SSTR) imaging. A second drawback in our case was that the patient was lost to follow-up, probably due to financial issues .Neuroendocrine tumors have a variety of clinical scenarios. These tumors should be kept in mind while dealing with patients with recurrent abdominal pain of unknown cause, requiring a high index of suspicion. Despite the advancement in imaging modalities, such tumors may not give clear clues of findings. Also, life-threatening causes of abdominal pain should be considered red flags and ruled out initially.


We report a case of ovotestis diagnosed in an adolescent, with a review of the literature.A 15-year-old patient presented with a right scrotal swelling associated with gynecomastia. Histology showed a juxtaposition of ovarian stroma with ovarian follicle and seminiferous tubules. Karyotype revealed a male subject (XY). We have therefore retained the diagnosis of ovotesticular disorders of sex development.Ovotestis is a rare finding, heterogeneous in its genetic etiology and clinical presentation. While many patients are diagnosed during infancy or childhood, we presented a case diagnosed in a 15-year-old adolescent.The online version contains supplementary material available at 10.1186/s12905-023-02698-1. The term ‘Disorders Of Sex Development’ (DSD) is now proposed to define congenital conditions in which a dysharmony between chromosomal, gonadal and anatomical sex exists . OvotestWe report a case of ovotestis diagnosed in a 15-year-old adolescent, describe the clinical presentation and diagnostic features.A 15-year-old patient, with no previous pathological history, raised as a boy, consulted the urology department of the University Hospital of Treichville for a right scrotal swelling, evolving for more than 5 years. The patient began full and normal male puberty at the age of 13.The clinical examination revealed a patient in good general condition, measuring 1.56 m and weighing 47 kg, corresponding to a body mass index of 19.31 kg/m². The patient had Tanner stage 2 pubic hair, with a penis measuring 4 cm at rest, without hypospadias or cryptorchidism.A painless, mobile and firm right scrotal mass was palpated. The left testicle was present but atrophic. He had a female morphotype, with marked gynecomastia Fig. . The lymOn pelvic and scrotal ultrasound, a right testicular solid tumor with a long axis of 6 cm was found, with absence of female genitalia. No uterus or adnexa was seen. The contralateral testis was without abnormality.The biological workup consisted of TESTOSTERONE (0.1 ng/ml), ESTRADIOL (20 ng/ml), ALPHA-FETO-PROTEIN (5 ng/ml) and β HCG (< 01ui /l); all of which came back normal.A right orchiectomy was performed and the specimen sent to the pathology laboratory.Macroscopically, it was a lumpy mass. On section, there were several whitish nodules surrounded by a yellowish border Fig. .The resected specimen was fixed with 10% formaldehyde, followed by conventional dehydration, kerosene embedding, sectioning and hematoxylin and eosin (HE) staining. On histology, there was a juxtaposition of ovarian stroma with ovarian follicle and seminiferous tubules Figs. , and 5. Hormonal therapy based on 80 mg testosterone undecanoate capsules at a dose of once a day and mastectomy were proposed, but the patient was lost to follow-up.Sexual ambiguities are congenital conditions with atypical chromosomal, gonadal or anatomical sex development . They ocApproximately 400 cases of ovotestis have been reported to date . AlthougOvotestis is a rare finding, heterogeneous in its genetic etiology and clinical presentation, its diagnosis is based on comprehensive clinical information, coupled with pelvic ultrasound and histopathology results, confirmed by karyotype. While many patients are diagnosed in infancy or childhood, we reported a case diagnosed in a 15-year-old adolescent with a 46, XY karyotype. This was diagnosed late due to normal male phenotypic development over time, with the need for long-term follow-up to assess hormonal status and sexual function. Because of the high risk of developing gonadal cancer in these patients, emphasis is placed on long-term multidisciplinary management, including psychologists, endocrinologists, gynaecologists, paediatricians and even plastic surgeons.Below is the link to the electronic supplementary material.Supplementary Material 1


Teaching point: Always ask a patient to open and close their mouth when you see a mass protruding into the external auditory canal, as to not miss this rare anomaly. A 66-year old man presented with an intermittent foreign body sensation and a mild pressure feeling in the left ear for the last five years. He didn’t perceive any hearing loss or other otologic complaints. Otomicroscopy revealed a mass at the antero-superior portion of the bony external auditory canal EAC), with an adhesion to the tympanic membrane . When he, with anTemporomandibular joint herniation into the EAC is a very rare condition and since it is mostly case reported, the exact incidence is unknown. A review  from 51


Postoperatively, the patient complained of bilateral leg numbness extending up to the T5 level, with bilateral paraplegia. An urgent laminectomy was performed, and we noted that the spinal cord was compressed by two masses of Surgicel® with blood clots measuring 1.5 × 1.5cm at T4 and T5 levels. The paraplegia did not improve despite the removal of the mass, sufficient decompression, and aggressive postoperative physiotherapy. Surgeons operating in fields close to the intervertebral foramen should be aware of the possible threat to the adjacent spinal canal as helpful hemostatic agents can become a preventable threat.Post-thoracotomy paraplegia after non-aortic surgery is an extremely uncommon complication. A 56-year-old woman presented with a 1-year history of progressive shortness of breath. Computed tomography revealed a locally advanced posterior mediastinal mass involving the ribs and the left neural foramina. Tumor excision with a left pneumonectomy was performed. Post-resection, bleeding was noted in the vicinity of the T4-T5 vertebral body, and the bleeding point was packed with oxidized cellulose gauze (Surgicel Post-thoracotomy paraplegia caused by hematoma and oxidized cellulose compression is a rare but devastating complication, with 15 cases reported between 1984 and 2017.,3 In this report, we present a case of paraplegia caused by spinal compression by Surgicel® after resection of thoracic chondrosarcoma.Post-thoracotomy paraplegia in non-aortic surgery is an extremely uncommon complication, with an estimated incidence of 0.08%.th and 5th rib as well as the T4 and T5 left neural foramina. Surgery was performed under general anesthesia using a double-lumen endobronchial tube. After single-lung ventilation was established, the patient was placed in the right lateral decubitus position. Thoracotomy via a posterolateral skin incision was performed through the 5th intercostal space. Intraoperatively, a tumor invading the left upper and lower lobes of the lung was noted; hence, a decision was made for tumor excision with left pneumonectomy, and the tumor part that invaded the neural foramina was easily removed with minimal dissection. However, after tumor removal, bleeding from the neural foramina of the T4 and T5 vertebral bodies was observed, which was difficult to control despite the use of electrocautery. An oxidized cellulose gauze (Surgicel®) was packed into the T4 and T5 neural foramina to achieve hemostasis.A 56-year-old female with a 1-year history of left-sided chest pain and worsening shortness of breath was admitted to our hospital for a workup. Contrast-enhanced computed tomography of the thorax showed a posterior mediastinal mass measuring 17 × 25 × 9cm with no clear plan between the posterior 4® with blood clots measuring 1.5 × 1.5cm at the T4 and T5 level (The patient was admitted to the intensive care unit. Upon awakening from anesthesia, she complained of bilateral lower limb numbness extending up to the T5 level, with bilateral paraplegia. At a 12-hours postoperative period, magnetic resonance imaging  was perfT5 level . The masT5 level . Unfortu® was used, left in situ, and was later found within the spinal canal during exploration. Oxidized cellulose is commonly used as a hemostatic agent. Once soaked in blood, it expands into a gelatinous mass, which aids in the formation of a clot, possibly exerting a compressive effect on the surrounding structures. This case report discusses the potential risk of iatrogenic spinal cord injury when oxidized cellulose is used as a hemostatic agent near the neural foramina region.These reports share many features with our case, namely, posterolateral thoracotomy with difficulty in achieving hemostasis near the paravertebral area despite using diathermy. Surgicel Although there is no connection between the pleural cavity and epidural space under normal circumstances, disruption during surgery may create such connections. Some authors have postulated that in the presence of a connection, the pressure difference between these two cavities drives oxidized cellulose to migrate into the spinal canal through the intervertebral foramen, causing spinal cord compression.-6 These studies also stipulated that the most difficult bleeding occurred near the end of the posterior rib, and in all cases, bleeding was only controlled with oxidized cellulose after attempts at pressure and diathermy.-7The spinal canal is only a few millimeters from the intrathoracic opening of the intervertebral foramen. Thus, in the setting of neurological deficits after thoracotomy, especially in instances where compressive hemostatic agents are left in situ, the surgeon must always have a high index of suspicion and act immediately to obtain both neurological consultation and imaging. If decompression is performed within 8 hours after the symptoms are described, the incidence of paraplegia is approximately 20%, whereas after 24 hours, the risk of paraplegia can increase to 60%.8Paraplegia after thoracotomy for non-aortic surgery requires urgent investigation and intervention to salvage spinal cord function and prevent subsequent morbidity. Magnetic resonance imaging revealed two well-defined hypointense masses on T1- and T2-weighted images. These characteristics are similar to the previously reported case as it also emphasizes the difference of contrast appearance between hematomas which appears as hyperintense and spread out in comparison to Surgicel® are used as hemostatic agents, attempts should be made to remove them all to avoid any serious and preventable complications.Surgeons operating in the thoracic cavity near the intervertebral foramen should be aware of the possible threat to the adjacent spinal canal because a meticulous surgical technique with good visualization of the operative field is imperative to reduce the risk of excessive bleeding. Resection of the ribs is necessary to salvage the operative field. In cases where Surgicel


We report a 46-year-old male patient with retinocytoma who presented at the age of 31 asymptomatically. An intraocular retinal mass was incidentally found in his right eye, when he underwent ophthalmological assessment for refractive surgery. This tumor consisted of a calcified sessile basis partially covered by a pedunculated salmon-pink growth. Initially, the tumor was diagnosed as a retinocytoma with clinical suspicion of malignant transformation into retinoblastoma and treated by four sessions of laser photocoagulation. Six and a half years later, the tumor relapsed, and he was treated with a Ruthenium plaque. Following brachytherapy, he had two episodes of right-sided vitreous hemorrhage that spontaneously cleared up, and the remaining finding in the vitreous cavity was interpreted as asteroid hyalosis. He underwent vitrectomy about five years following brachytherapy. The analysis of the vitreous material revealed the presence of inactive vitreous seeds composed of small round blue cells, compatible with a type 2 regression. Retinocytoma is a rare benign tumor of well-differentiated, mature retinal cells that very seldom undergo malignant transformation into retinoblastoma. It was first described by Gallie et al. as a retinoma with the characteristic clinical features that included a grey, translucent retinal mass, calcification, and hyperplastic retinal epithelium or chorioretinal scar . SeedingThe patient intended to undergo refractive surgery at the age of 31 due to professional requirements. The preoperative ophthalmological examination revealed a right-sided intraocular retinal mass, and he was referred for further examination and investigation. The family history was negative for ocular tumors. The best corrected visual acuity was 1.0 in both eyes, and the examination of the anterior segment of both eyes and the posterior segment of the left eye were within normal limits. Fundus examination of his right eye revealed an intraocular retinal mass located in the superotemporal quadrant . The uppIt is essential to differentiate retinocytoma from retinoblastoma since the latter is a malignant condition and requires treatment. Retinoblastoma is most likely to be diagnosed before the age of 5, while retinocytoma is commonly asymptomatic and more likely to be diagnosed in older children and adults. Retinoblastoma typically demonstrates growth within the first months and would most likely not have retinal pigment epithelial changes. Singh et al. reported a translucent retinal mass in 88%, calcifications in 63%, and retinal pigment epithelial changes in 54% of the retinocytoma cases. The presence of all three clinical features was found in 33% of retinocytoma patients [Nonprogressive retinal tumor has been termed “spontaneous regression” of retinoblastoma, and affected patients may or may not carry a constitutional RB1 mutation . DiffereBoth retinocytoma and retinoblastoma carry biallelic mutations in the RB1 gene , 9. RetiRetinocytoma is diagnosed clinically and requires annual controls due to the risk of malignant transformation with an estimated lifelong probability of 5% .


Background: Asymptomatic patients at average risk of developing colorectal cancer are encouraged to undergo screening colonoscopy beginning at age 45 years. While ileal intubation is often considered the gold standard for a complete colonoscopy, the relatively low diagnostic yield has prevented widespread adoption. Small bowel cancers, including neuroendocrine tumors, may present incidentally as terminal ileitis on routine colonoscopy with terminal ileum intubation. Neuroendocrine tumors, the most common primary neoplasm of the small intestine, are often asymptomatic or present as nonspecific abdominal pain in the sixth or seventh decade of life.Case Report: A 51-year-old asymptomatic male with unremarkable physical examination underwent screening colonoscopy that revealed scattered ulcerations of the terminal ileum. Immunohistochemistry of the lesion was consistent with well-differentiated neuroendocrine tumor, World Health Organization Grade I. DOTATATE positron emission tomography/computed tomography demonstrated avid adjacent right mesenteric lymph node and avid focal pancreatic body lesion. Fine-needle biopsy and immunohistochemistry of the pancreatic lesion confirmed neuroendocrine tumor, while the mesenteric lymph node was found to be benign. The patient underwent robotic-assisted ileocolic resection and has ongoing surveillance of the pancreatic lesion.Conclusion: Terminal ileitis encompasses a host of pathologic processes, including inflammatory states, infectious disease, malignancy, and vasculitis. Importantly, small bowel cancer is an increasing cause of terminal ileitis. Screening colonoscopy with ileal intubation can be a valuable tool for early detection of these lesions. The patient was at average risk for colon cancer with no known personal or family history of colorectal cancer. He was a never-smoker and had had no previous surgeries. The patient's physical examination findings on presentation were unremarkable.Screening colonoscopy demonstrated scattered, clean-based, 1- to 3-mm ulcerations of the terminal ileum with patchy erythema and edema . BiopsieStaging imaging with computed tomography of the chest, magnetic resonance imaging (MRI) of the abdomen, and DOTATATE positron emission tomography/computed tomography (PET/CT) demonstrated ileocecal junction lesion, avid adjacent right mesenteric lymph node, avid focal pancreatic body lesion, and nonavid enlarged subcarinal lymph node. Because of concerns about regional lymph node involvement and possible distant metastasis, esophagogastroduodenoscopy (EGD), upper endoscopic ultrasound (EUS) with fine-needle biopsy, and bronchoscopy were performed. EGD was unremarkable. However, EUS revealed a focal, well-circumscribed hyperechoic lesion of the pancreatic body measuring 10.1 × 7.7 mm consistent with a primary neuroendocrine tumor . Fine-neImmunohistochemistry of the pancreatic lesion revealed CD56, synaptophysin, and chromogranin positivity, supporting the diagnosis of neuroendocrine tumor. Bronchoscopy with sampling of a station 7 lymph node was negative for malignant findings.Because of the presence of multiple neuroendocrine tumors, the patient was referred for genetic testing, but he did not undergo the testing.The patient underwent robotic-assisted ileocolic resection. Final pathology revealed a stage III, WHO Grade I well-differentiated neuroendocrine tumor with involvement of 6 of 15 lymph nodes. He was discharged home after an uneventful 2-day hospital stay. At 2-week and 3-month follow-up, the patient was doing well with no acute concerns.The patient's pancreatic neuroendocrine tumor was discussed during multidisciplinary conference with surgical oncology. Given the lesion size <2 cm, the patient was enrolled in a surveillance program. CT scan of the chest, abdomen, and pelvis at the 3-month follow-up appointment revealed no evidence of distant metastases. At the 10-month appointment, the pancreatic lesion was no longer evident on MRI of the abdomen. The patient is set to return to the surgical oncology clinic in 6 months for repeat abdominal MRI and PET/CT.8 Inflammation is often noncontiguous, manifesting as skip lesions between the mouth and the anus. These skip lesions may progress into ulcers that eventually form fistulas and strictures. Histologically, Crohn disease is characterized by the formation of noncaseating granulomas. In contrast to Crohn disease, ulcerative colitis is restricted to the mucosa and/or submucosa, involves continuous colonic lesions, and is characterized histologically by the formation of crypt abscesses. The development of terminal ileitis in ulcerative colitis is secondary to a weakened ileocecal valve, whereby colonic contents are refluxed into the terminal ileum, a condition called backwash ileitis.8 Backwash ileitis is estimated to occur in up to 17% of patients with ulcerative colitis.9 Ileal erosions can occur but are rare.8Terminal ileitis encompasses a host of pathologic processes, including inflammatory states, infectious disease, malignancy, and vasculitis. Most commonly, terminal ileitis is discussed within the context of Crohn disease, an idiopathic transmural inflammation of the gastrointestinal tract.Mycobacterium tuberculosis. Although the incidence of tuberculosis has continued to decline in the United States,10 the immunocompromised, including patients with HIV and patients receiving biologic therapy, remain at risk for development of intestinal tuberculosis.8 Notably, ileocecal involvement has been observed in nearly 90% of patients with intestinal tuberculosis.12 Ileocecal involvement is likely the result of the high density of lymphoid cells in the terminal ileal area, as well as a favorable growth environment.7 Chronic inflammation in the setting of intestinal tuberculosis results in the development of fibrosis and/or stenosis, as well as tuberculomas that can perforate the terminal ileum.7 Because intestinal tuberculosis may present similarly to Crohn disease and ulcerative colitis, culture, polymerase chain reaction testing, and biopsy are essential in the diagnostic approach.13Intestinal infections are another important consideration in the differential of terminal ileitis. One such infection is 14 Small bowel injury can vary from mild mucosal inflammation to ulceration. While rarely seen, diaphragmatic strictures are pathognomonic for chronic NSAID use.15 Patients are generally asymptomatic, although some present with iron-deficiency anemia.Another consideration in the workup of terminal ileitis is chronic nonsteroidal anti-inflammatory drug (NSAID) use. Although NSAID use is more commonly associated with peptic ulcer formation, the prevalence of NSAID-induced enteropathy is increasing.16 The withdrawal of the offending drugs results in resolution of the findings. In some cases, treatment with systemic steroids may be required.20Medications other than NSAIDs have also been implicated in the development of terminal ileitis. Immune checkpoint inhibitors have been found to cause terminal ileitis.7 Between 1975 and 2018, the incidence of small bowel cancer per 100,000 individuals in the United States increased from 1.1 to 2.4, a 118% increase.21 Among these cancers, neuroendocrine tumors are a type of slow-growing malignancy derived from endocrine cells. The most common primary neoplasm of the small intestine, neuroendocrine tumors most frequently present in the sixth or seventh decade of life.23 Since the 1970s, the incidence of small intestine neuroendocrine tumors has been rising, with analysis of the Surveillance, Epidemiology, and End Results registry through 2012 revealing an incidence of 1.05 per 100,000 persons.25 Notably, the terminal ileum is the most frequently implicated site within the small intestine.26Although not frequent, small bowel cancer is an increasing cause of terminal ileitis.28 However, as most patients report nonspecific abdominal pain or are asymptomatic, small intestine neuroendocrine tumors are often incidental findings on routine colonoscopy.26 Approximately 30% of patients will be metastatic at presentation, often to the liver.29Because of the secretion of neurotransmitters, including serotonin, neurokinin A, and histamine, patients with small intestine neuroendocrine tumors may present with symptoms consistent with carcinoid syndrome such as flushing, diarrhea, valvular heart disease, and bronchospasms.30 Although more expensive, MRI offers greater sensitivity than CT in detection of metastases.31 Physiologic function is often assessed by PET/CT in conjunction with somatostatin receptor radiotracers Ga-DOTATOC, Ga-DOTANOC, or Ga-DOTATATE.32 In addition, patients with small intestine neuroendocrine tumors suspected of having carcinoid syndrome may undergo biochemical testing. Among the many biomarkers to choose from, chromogranin A and 5-HIAA are favored for their high sensitivity and specificity.33Small intestine neuroendocrine tumors can be diagnosed with anatomic imaging, functional imaging, biochemical workup, or endoscopic examination. Most commonly, patients undergo a multiphase CT scan.35 To determine the appropriate WHO classification of the small intestine neuroendocrine tumor, the Ki-67 proliferative index and mitotic rate are quantified.36Pathologic examination is necessary to confirm the initial diagnosis of small intestine neuroendocrine tumor. Besides histology, immunohistochemistry with chromogranin and synaptophysin is frequently performed.37 Notably, a retrospective study of well-differentiated small intestine neuroendocrine tumors treated with surgical resection found a 42% recurrence rate, with liver metastases identified in 64% of those who relapsed.38 In cases of metastases, somatostatin analogs are preferred as the first-line management because of their antiproliferative effects and ability to suppress carcinoid symptoms.40The preferred management of locoregional small intestine neuroendocrine tumors is surgical resection, with segmental small bowel resection or ileocecectomy with regional mesenteric lymphadenectomy.40 The prognosis for small intestine neuroendocrine tumor remains favorable, with a median survival of 103 months for patients with moderately and well-differentiated tumors and a 5-year survival rate of 69%.25Given the slow rate of regrowth of small intestine neuroendocrine tumors, asymptomatic patients are initially closely monitored with radiographic imaging , transitioned to 6-month surveillance appointments, and then followed annually with imaging and clinical and biochemical workup for 10 years.This case underscores the importance of screening colonoscopy with ileal intubation in the detection of asymptomatic neuroendocrine tumors of the small intestine. Furthermore, this case serves as a reminder that such neoplasms, although rare, should remain on the differential when considering lesions of the terminal ileum.