We present the case of a 54-year-old woman who underwent right adrenalectomy for palliation of Cushing’s symptoms. She had recently been diagnosed with lung adenocarcinoma. Pathologic findings revealed a 5 cm adrenal adenoma with a metastatic adenocarcinoma deposit. The occurrence of tumor-to-tumor metastasis is rare, and the finding of a metastasis within a functional adrenal adenoma exceptionally so. Previously reported incidences of this finding in patients with lung cancer range from 0.14% to 0.63%. We review the literature regarding this unusual finding. Tumor-to-tumor metastasis is an infrequent occurrence. Here we report on the finding of metastatic lung adenocarcinoma within a functioning adrenal adenoma which was excised for palliation of Cushing’s symptoms in a 54-year-old female.A 54-year-old Caucasian American female who previously had a hiatal hernia repair was referred for abdominal CT scan after operative findings of hepatomegaly were noted. On CT  and subsAt laparoscopy, a 5 × 4 × 4 cm, 45 g right adrenal mass was identified and removed without complication . The patThe occurrence of adrenal metastasis in the setting of non-small cell lung cancer (NSCLC) is not uncommon. In patients with NSCLC, the incidence has been reported from 25-40% during the course of the disease ,2. AdrenDespite the relative frequency of adrenal metastasis, this finding in the setting of an adrenal adenoma is rare. This phenomenon has been studied by Moriya et. al who noted a 0.63% incidence of metastasis to an adrenal adenoma in a review of lung cancer autopsy cases . The staTumor-to-tumor metastasis is an uncommon occurrence, and has only been documented in sporadic case reports and series since 1902 . Fewer tGenerally, the presence of an adrenal metastasis in the setting of lung cancer classifies the patient as having Stage IV disease and therefore benefiting most from chemotherapy. There is some evidence that patients with otherwise surgically resectable lung cancer and documented isolated adrenal metastasis may benefit from simultaneous resection . This diThe authors are not aware of other cases of NSCLC metastasis to a functioning adrenal adenoma. Tumor-to-tumor metastasis has been reported in the setting of a non-functioning adenoma . The priEarly identification of adrenal metastases is essential as adrenalectomy may improve survival in selected patients. To this end, physicians caring for patients with lung cancer must maintain a high index of suspicion to detect these lesions.


Acute chylous ascites is a rarely seen clinical picture, therefore, examination findings are often confused with acute appendicitis. To the best of our knowledge, there is no publication to date showing the occurrence of them together. This study presents the treatment plan for a 25-year-old male patient with both acute chylous ascites and appendicitis. Surgical findings were retrocaecal appendicitis, evident lymphangiectasia in the proximal segment of jejunum, and approximately 3 lt of chylous fluid. An appendectomy was performed and drainage was applied. Low-fat total parenteral nutrition (TPN) and octreotide treatment were administered for 7 days postoperatively. We also present a general review of some studies on chylous ascites, which have been published in the English language medical literature since 1910. Chylous ascites is a milky or creamy fluid, rich in triglycerides, which accumulates in the peritoneal cavity –6. ExtraThis study aimed to give the clinical presentation of a 25-year-old male patient, who was admitted for surgery with signs and symptoms of both acute appendicitis and acute chylous peritonitis. We also give an overview of the studies on chylous ascites published in the English language medical literature and until now, no causal link has been detected between chylous ascites and appendicitis.A 25-year-old male presented to the emergency department with abdominal pain, bloating, nausea, and vomiting. According to his history, the abdominal bloating and pain had started 3 days before and the patient had been prescribed painkillers, proton pump inhibitors (PPIs), and antiflatulence medication. In the morning of the day he came to our clinic, the patient had complaints of nausea and vomiting, and widespread abdominal pain developed. During the day, the pain had become more localized in the lower right quadrant and he presented to our clinic around 09.00 pm. The patient reported absence of bowel movements for 2 days. The patient history showed no alcohol or tobacco use, no chronic illness, and no trauma or surgical intervention. Physical examination revealed a temperature of 38°C, moderate dehydration, abdominal distension, and definite rebound in the lower right quadrant. On auscultation the intestinal bowel sounds were slightly reduced and digital rectal examination showed an empty ampulla. Laboratory results were WBC 12.400 K/UL (4.3–10.3), haemoglobin 13.8 gr/dL (13.5 17.2), BUN 55 mg/dL (10–45), and creatinine 0.98 mg/dL (0.6–1.2). AST, ALT, ALP, GGT, amylase, lipase, HDL, LDL, triglyceride, and albumin values were within normal limits. The abdominal ultrasonography revealed minimal fluid between intestinal segments in the lower right quadrant and in the pelvic area. The abdominal radiograph showed several small areas of air and fluid. Due to these findings, the patient was admitted for surgery with an initial diagnosis of perforated appendix. The abdomen was opened with a McBurney incision. When the peritoneum was opened, milky peritoneal fluid was observed. Then the retrocaecal appendix was freed and due to its inflammation, appendectomy was performed. However, after the aspiration of 2.5–3 lt of fluid, a perforation of an abdominal organ was presumed, and midline incision was made into the abdomen. The milky fluid was seen in all quadrants of the abdomen. After aspiration of the fluid, on the wall of the proximal jejunal segment 10 cm distal to the Treitz ligament, an expanded lymphatic network with a lymphangiectasic structure was seen . Two draChylous ascites is a rare form of ascites resulting from the collection of lymphatic fluid in the abdominal cavity and is seen in 1 out of 20,000 patients presenting to hospital . ChylousIt occurs when there is no underlying disease and findings of peritoneal irritation develop due to the rapid collection of fluid in the peritoneal cavity. Patients suffer from loss of appetite, nausea, vomiting, and pronounced abdominal pain related to the peritoneal irritation. Biochemical and microbiological analyses are necessary in this situation , 6.It generally appears clinically without pain and with increasingly distended abdomen. Symptoms as loss of appetite, weakness, and abdominal pain are often seen but not specific. As the fluid collects slowly, the abdominal cavity adapts, and complaints are tolerated by the patients , 6, 8.When we look at the literature, acute ascites is seen less frequently in comparison with the chronic form . In a puCongenital Reasons: for example, chyle cysts, congenital lymphangiectasia, lymphatic hypoplasia, and idiopathic reasons; the majority of cases of chylous ascites in childhood are in this group. Acquired Reasons: for example, malignant diseases, after abdominal or thoracic surgery, abdominal tuberculosis, pancreatitis, filariasis, inflammatory diseases such as retractile mesenteritis, blunt or penetrating trauma, volvulus, obstructions caused by herniation and bridges, cirrhosis, hemodynamic malfunctioning due to cardiac, and renal insufficiency; they are more often seen in adults. The reasons are well summarized in the table of the study entitled “Causes of chylous ascites” by Smith et al. [The etiology of chylous ascites can be congenital or acquired. h et al. . Three dObstruction of the lymph flow caused by external pressure (mass) leading to leakage from dilated subserosal lymphatics into the peritoneal cavity.Exudation of lymph through the walls of dilated retroperitoneal vessels lacking valves, which leak fluid through a fistula into the peritoneal cavity as in congenital lymphangiectasia.Traumatic thoracic duct obstruction causing direct leakage of chyle through a lymphoperitoneal fistula , 6, 11.A comparison based on geographical characteristics as an etiological factor showed that in Europe and North America, two-thirds of all patients had malignant diseases and cirrhosis, whereas in South America and Asia, tuberculosis and infectious diseases such as filariasis were more frequently seen , 7, 11.In a study by Lerrick et al. , 30 caseAccording to Thompson et al. , a totalHolcomb et al.  noted a According to Hardy et al. , there wLiu et al. reviewed in a study 10 cases of chylous ascites  developing secondary to pancreatitis between 1953 and 2001 , 11, 14. Acute chylous ascites with no trauma history or other specific agent is referred to as spontaneous chylous ascites. Most cases of spontaneous chylous ascites in the literature occur in young adults and they are generally admitted for surgery with a diagnosis of acute appendicitis , 6. In cThe most important stage of the diagnosis is preoperative suspicion, then the radiological and biochemical results can be of benefit. Abdominal fluid can be seen on USG performed in the emergency department, but the clinician may interpret this as a perforated appendix. Blood biochemical analysis may not show excessive changes, so the most important diagnostic tool is paracentesis, which can be of considerable value in making the diagnosis of chylous ascites if the fluid is milky or creamy, triglycerides >2.24 mmol/L and glucose <5.5 mmol/L , 3, 4. ITheoretically, CT, lymphangiography, and lymphoscintigraphy can also be used. However, according to the studies in the literature, most patients were evaluated under emergency conditions and the decision about surgery was made. It is not possible to carry out all these diagnostic tests under emergency conditions. A significant proportion of cases of chylous ascites has developed in cases of cirrhosis of the liver and intra-abdominal malignancies, therefore, these tests can be useful for observation during the chronic period .The choice of medical approach to the disease depends on the etiology. Under emergency conditions, a simple paracentesis can relieve pressure in the abdomen, prevent renal function failure, make the patient more comfortable, and give the clinician the opportunity to analyse the fluid for diagnosis. Patients with acute abdominal findings should be investigated immediately. Laparotomy is the first choice to confirm the diagnosis, to explain any underlying causes and for the necessary treatment to be applied , 3, 4. TIn conclusion, although chylous ascites and appendicitis are rarely seen together, when there is a suspicion of ascites findings on abdominal examination, a simple paracentesis and immediate USG can direct the appropriate treatment plan.


Leiomyosarcomas are rare tumors. The most common site for head and neck leiomyosarcomas is the oral cavity, followed by sinonasal tract and skin. Subcutaneous leiomyosarcomas are thought to arise from small to medium-sized blood vessels in the subcutaneous tissue.A 67-year-old female patient underwent excision of a slow growing neck mass of the left posterior neck triangle after a thorough clinical and laboratory examination. The lesion was located in the subcutis and fine needle aspiration biopsy revealed malignant features. Histology revealed subcutaneous leiomyosarcoma and the patient is free from local recurrence and distant metastases 3 years after wide excision of the lesion.The primary modality of therapy of subcutaneous leiomyosarcoma is surgery, adjuvant radiotherapy or chemotherapy may be used for control of local recurrence, in case of positive surgical margins, high-grade or large tumors. Soft tissue sarcomas compromise approximately 0.7% of all malignant neoplasms, and leiomyosarcomas (LMSs) have been reported to account for 3-7% of soft tissue sarcomas . LMSs arSubcutaneous LMS is thought to arise from small to medium-sized blood vessels in the subcutaneous tissue . It is aA 67-year-old Greek woman, presented in the General Hospital of Volos with a painless neck mass on the left Fig. . No prevHistology showed a low grade nodular malignant mesenchymal neoplasm consisting of perpendicularly arranged fascicles of spindle cells with eosinophilic fibrillary cytoplasm, scattered pleomorphic nuclei and irregular mitosis with a rate of 6 to 8 per 10 high-power-fields Fig. . The lesSoft tissue sarcomas are relatively rare neoplasms that may arise in any anatomic region. Occurrence in the head and neck accounts for less than 1% of all malignant tumors in this site . SarcomaTreatment of subcutaneous LMS is dictated by stage, location, size and patient age. The primary modality of therapy is surgery which must be designed to be curative. A wide excision with 3-5 cm lateral margins and a depth that includes subcutaneous tissue and fascia is recommended. Lymph node metastasis in head and neck sarcomas account for 10 to 15% of cases and neck dissection is not required for staging or treatment . RadiothManagement of a neck mass may surprisingly reveal a rare lesion such as subcutaneous leiomyosarcoma. A thorough clinical and laboratory examination is essential in order to achieve fast diagnosis and curative excision of this aggressive tumor. The primary modality of therapy of subcutaneous LMS is surgery, which must be designed to be curative. Adjuvant radiotherapy or chemotherapy may be used for control of local recurrence in case of positive surgical margins, high-grade or large tumors.LMS: leiomyosarcoma; FNA: fine needle aspiration; BMI: body mass index; α-SMA: smooth muscle actin; HHF-35: muscle-actin-specific monoclonal antibody; S-100: specific protein tumor-marker; CT: computed tomography; MRI: magnetic resonance imaging; HPF: high-power fields.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.CS and PT were the doctors that the patient presented to, performed the FNA as well as the surgical excision, TC and CP followed the patient in the postoperative period. All authors have discussed and make discissions for the treatment procedure followed. All authors have contributed in the manuscript writing. All authors read and approved the final manuscript.


A 24-year-old man presented himself with a nodular lesion of about 1 cm diameter at the site of a previous orchiopexy associated with surgery for cryptorchism. Histopathology revealed the lesion to be adenomatous and confined to the scrotum. Histological and immunohistological features were not consistent neither with median raphe cysts or cutaneous adenomas nor with the intrascrotal adenomas of the rete testis, epididymis, nor with  mesotheliomas. However, the lesion did compare well with serous (papillary) cystadenomas of the testis or paratestis. These adenomas are thought to originate in remnants of the Müllerian system or of peritoneal lining altered by Müllerian metaplasia. This implies that the scrotal adenoma may have developed from an implant of such elements during orchiopexy 14 years ago. Complete excision of the lesion appears to be an adequate therapy. Tumors and tumor-like lesions in the scrotum comprisea wide spectrum of conditions related to the scrotum and to the testis andparatestis , 2. ThesIn 2004, Hara et al.  describeA 24-year-old male noticed a circumscribed swellingin the skin of his left scrotum. Physical examination showed a 1.5 cm nodus atthe site of an orchiopexy performed for cryptorchism 14 years earlier. It wasexcised under local anesthesia under the suspected diagnosis of pilar cyst. Noconnection with intrascrotal structures was noticed.Macroscopy showed an ellipsoid 2.5 × 1.5 × 1 cm specimenwith a firm 1 cm tumor. Microscopic sections revealed an irregular tubulocysticepithelial proliferation surrounded by a mantle of connective tissue andembedded in the smooth musculature of the dartos fascia . ThetumA specially selected differential diagnostic panel ofimmunohistochemical tests demonstrated reactivity for cytokeratin (CK) 7 ,vimentin , Ca-25 ,estrogen receptor (ER),progesterone receptor (PR) (DAKO), nonreactivity for CK 20 (DAKO), calretinin , and alpha-smooth muscle actin (SMA) . This profile was inconsistent with scrotal median raphecysts (nonreactive for vimentin) (three cases tested) and cutaneous papillaryhidradenomas (reactive for SMA in myoepithelium) (three cases tested). Withrespect to the possibility of a derivation from paratesticular structures (three cases tested),the immunoprofile of the tumor did not match those of the rete testis andmesothelium or epididymis . However, in concordance with cytological details, the profile of thetumor is similar to that of serous (papillary) cystadenoma of the ovary (threecases tested). The MIB1 cell proliferation index was 1.5%.The present case appears to be almost identical inclinical and histopathological aspects to those described by Hara et al. and DehnMedian raphe cysts are localized in the midlinebetween the preanal perineum and the external urinary meatus and typically showa urethra type of epithelium which is pseudostratified columnar epithelium withoccasional mucus production or cilia and often undergoes squamous metaplasia –8 cystadenomas of the paratestis (and ovary) , 13, 15 These cystadenomas are thought to originate inremnants of the Müllerian (paramesonephric) system and/or by Müllerianmetaplasia of the peritoneal lining of the tunica vaginalis , 12. In The precise nature of the tumor is still obscure. Thepresumed development of the lesion of Hara et al.  within tOrchiopexy maybe complicated by an adenomatous tumor morphologically identical to theMüllerian serous (papillary) cystadenoma of the paratestis. Confinement of thepresent lesion to the scrotum suggests implantation of Müllerian elementsduring the operation. The previous designation “median raphe cyst mimicking aserous borderline tumor” is incorrect. The still-limited data available suggestthat complete excision may be an adequate therapy.


Described as asymptomatic and an incidental finding on a plain x-ray film, the “pelvic digit” is a rare congenital anomaly. A 35-year-old man is of a rare symptomatic pelvic digit that warranted surgical excision. Its importance lies in its differentiation from acquired abnormalities due to trauma such as myositis ossificans and avulsion injuries of pelvis. If this entity is kept in mind, unnecessary investigations or interventions can be avoided. It is a rare congenital anomaly, in which bone tissue develops in the soft tissue. We report a symptomatic “pelvic digit”.A 35-year-old man, teacher by occupation, presented with complaints of pain in the left hip of six-year duration. His pain was insidious in onset, gradually progressive, and more on walking . The pain radiated to the ipsilateral gluteal region and thigh and was relieved with rest and analgesics. There were no constitutional symptoms and there was no history of trauma. He was unable to sit cross-legged and had difficulty in climbing stairs and squatting.Examination revealed a hard mass on the lateral aspect of the left hip, superior to the trochanter. The mass did not move with the trochanter. There was no tenderness in the hip joint line. He had tenderness at the upper end of the mass, near the iliac crest. His movements were as follows: flexion 0-120°, extension 0-10°, abduction 0-20°, adduction 0-10°, internal rotation 0-10°, and external rotation 0-40°. A clinical diagnosis of myositis ossificans was made. All blood investigations were within normal limits including serum calcium (8.7 mg %), phosphorus (3.3 mg %), and alkaline phosphatase (65 IU). Serum uric acid was 3.8 mg %. Plain x- ray films revealed a bony finger-like mass arising from the lateral aspect of the iliac wing, which extended up to the tip of the greater trochanter . It had The pelvic digit was first reported by Sullivan and Cornwell in 1974, the lesion can be located at any level of the pelvic bones, lower ribs, or even in the anterior abdominal wall.232The radiographic entity of pelvic rib or digit, described earlier as an incidental finding, can be symptomatic, causing pain and restriction of movements and requiring surgical excision. Recognition of this entity is important, as it is usually benign and if asymptomatic, it is best left alone.8


Cystic lesions of pancreas include a myriad of different conditions ranging from the common pseudocyst to unusual cystic neoplasm. With the development of better imaging modalities, cystic neoplasms are diagnosed with greater frequency and accuracy leading on to better understanding of the natural course of these lesions. Serous cystadenoma is one of the rare neoplasms of the pancreas that is unique for its benign nature. Most of the time surgery is indicated for the symptom of pain when the lesion enlarges. Surgery may also be indicated due to the fact that, it may not always be possible to dogmatically differentiate it from the potentially malignant counterpart radiologically. One of the interesting aspects about serous cystadenoma is its association with other systemic disorders like von Hippel Lindau syndrome. Herein we report a rare association of serous cystadenoma with mediastinal lipoma, which has not been reported in the literature. A 50-year-old South Indian female presented with vague abdominal pain of six months duration. Clinical examination revealed a vague mass in the left upper quadrant. There were no palpable mass in the neck or chest. Blood investigations were found to be normal. Ultrasound abdomen showed a mixed echogenic lesion in the tail of the pancreas measuring 7 × 5 cm. CECT (Contrast enhanced computerized tomogram) showed a well defined lesion arising from the tail of the pancreas predominantly hypodense with heterogenous contrast enhancement . CECT alCystic lesions of the pancreas constitute a wide variety of conditions which include pseudocysts, true congenital cysts and cystic neoplasms . Cystic Serous cystadenoma of the pancreas, also called microcystic adenoma or glycogen rich adenoma is unique for its benign nature with little malignant potential . PancreaOn ultrasound the lesion appears as a solid echogenic mass due to the myriad of interfaces produced by the numerous cysts. CECT shows a swiss cheese appearance with gentle external lobulation. A central stellate scar with calcification may be seen in 20% of the cases. The lesion appears hypointense on T1 weighted sequence and hyperintense on T2 weighted sequence of MRI.Serous cystadenoma may be associated with other disorders which include von Hippel Lindau , Evans s


Endometrial cancer is the most common gynecologic malignancy. Most women present with abnormal vaginal bleeding. Cervical stenosis can prevent early uterine bleeding leading to delayed diagnosis of the disease.A 67 years old Caucasian woman presented with three days history of right flank pain and difficulty in urination. Her medical history included cervical cautery due to ectropion 15 years previously. In physical exam a huge cystic mass that proved to be a large hematocervix was bulging in the vagina. Computed tomography of the abdomen revealed a distended cervix adjacent to distended urinary bladder secondary to endometrial cancer.To our knowledge this is the first case report describing acute urinary retention secondary to hematocervix. Cervical stenosis is common in elderly postmenopausal women and can prevent early manifestation of endometrial pathology and can be associated with local complications. Endometrial cancer is the most common gynecologic malignancy and the fourth most common cancer in women . It has A 67 years old Caucasian woman gravida 3, para 1 presented with three days history of right flank pain and difficulty in urination. Her medical history was significant for obesity, hypertension and previous salpingectomy due to ectopic pregnancy. 15 years previously a cervical cautery was performed due to cervical ectropion.On admission her vital signs were stable. Physical examination revealed tenderness in both costovertebral angles and fullness in the lower abdomen. In gynecologic exam a huge soft cystic mass was bulging in the vagina to the level of the hymen. It was suspected to be a distended cervix. The external cervical os was not identified.Computed tomography of the abdomen revealed a distended urinary bladder with bilateral hydronephrosis and hydroureter. Adjacent to the bladder was a cystic mass of 10 cm in the pelvis that was suspected to be a dilated cervix figure . No asciAn explorative laparatomy was performed; the uterine cervix was found to be distended with very thin walls and when was incised proved to be a large hematocervix and about 700 ml of old blood was drained. Due to cervical distention and difficulty differentiating the margins of the cervix from the vagina a modified radical hysterectomy was performed. Due to suspected malignancy, surgical staging was completed by omentectomy and lymph node dissection.Histological examination of the specimens revealed grade I adenocarcinoma of the uterus located in the fundus with more than two thirds myometrial invasion. There was no lymph-vascular space involvement. The lower uterine segment, cervix and omentum were free of disease. Two of the pelvic lymph nodes were positive for metastases; stage IIIC according to the International Federation of Gynecologists and Obstetricians staging system. Following surgery the patient was treated by pelvic radiation and was doing well one year after surgery with no signs of disease recurrence.Acute urinary retention is unusual and rare manifestation of endometrial cancer. We assume that the previous cervical cautery resulted in cervical stenosis that concealed the uterine bleeding. The continuous blood accumulation distended the cervix and posed direct pressure on the adjacent urethra causing urinary obstruction. Bolton et al  describeCervical stenosis can lead to delayed detection of endometrial pathology. It is common in postmenopausal women and can result from aging, infection, malignancy, previous surgery or radiation. In our case, cervical distention is the result of continuous uterine fluid accumulation. Uterine fluid collection can be found in approximately 9-12% of asymptomatic, post-menopausal women ,4 and isDelayed diagnosis of endometrial cancer affects prognosis, Schneider et al  describeThis case demonstrate an unusual and rare presentation of endometrial cancer causing cervical distension and urinary retention. It is the end stage result of continuous fluid accumulation in the uterus and mainly the cervix. To our knowledge this is the first case describing urinary retention secondary to hematocervix. Uterine fluid demonstration is common in postmenopausal women and is frequently associated with cervical stenosis, such cases must prompt early assessment to rule out underlying malignancy.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.ST and IA contributed equally in writing this manuscript. IA Performed the gynecologic surgery. ST and IA followed the patient in the gynecologic oncology unit. All authors read and approved the final manuscript


Carcinoid tumours are well-differentiated neuroendocrine tumours with secretory properties. Although fairly rare, they are the most common malignancy seen to affect the distal small bowel. Presentation is often non-specific with symptoms mimicking those of irritable bowel syndrome. Given this, the condition is often diagnosed late following disease progression, by which time the prognosis is poor.A 74 year old Caucasian lady presented with a two week history of loose stools, nausea and one episode of vomiting. This sub-acute presentation occurred on a background of a four year history of intermittent abdominal pain and bloating, previously diagnosed as irritable bowel syndrome. CT scans identified dilated loops of small bowel proximal to a spiculated mass in the region of the terminal ileum. This ileal lesion was removed at laparotomy and identified as a carcinoid tumour.This case highlights the issue of misdiagnosis of intestinal malignancy as the benign condition of irritable bowel syndrome. There have been several other references to this happenstance in the literature, and the problem is reflected in the percentage of patients with widespread disease at the time of diagnosis. Prognosis in this condition can be dramatically improved with early diagnosis, and surgical management at this stage is often curative. For this reason it is imperative to keep this differential diagnosis in the back of one's mind when assessing patients presenting with symptoms of intermittent partial bowel obstruction. The clinical presentation of this tumour, along with investigation and management of these cases, is discussed here. Midgut carcinoids are generally well-differentiated neuroendocrine tumours with secretory characteristics. An occurrence rate within the small intestine of 1 in 300 has been reported at autopsy, making it the most common distal small bowel malignancy . These aA 74 year old lady presented to the emergency department following a fall. On further questioning she reported a two week history of loose stools, mild abdominal pain and one episode of vomiting. These symptoms occurred on a four year background of intermittent abdominal pain and bloating for which she had been referred to a surgical outpatient clinic three years previously. Following a normal gastroscopy and colonoscopy she was diagnosed with irritable bowel syndrome.Physical examination showed abdominal distension with generalised tenderness and active bowel sounds. She was clinically dehydrated and blood tests revealed a low potassium of 2.9 and elevated urea of 12.9. The patient underwent an abdominal CT scan which identified dilated loops of small bowel proximal to a spiculated mass in the region of the terminal ileum with mesenteric lymph nodes. Multiple small lesions within the liver were also noted. [Figure At laparotomy the surgical team located the lesion within an ischaemic terminal ileum. They also found significant mesenteric lymphadenopathy. The team carried out a small bowel resection with ileo-caecal anastomosis. At histology the lesion within the terminal ileum was identified as a carcinoid tumour measuring 2 cm, with mesenteric nodal metastasis in the proximal ileum. The patient made a good post-operative recovery and went on for further assessment to identify metastatic disease.The term carcinoid was first used to describe 'hormonally active' tumours in 1907 by Oberndorfer . They arClinical presentation can be with non-hormonal symptoms secondary to tumour bulk and local reaction, or with symptoms of a functioning tumour, described as 'carcinoid syndrome'. Tumours arising in the small intestine are often silent until late in the disease and are thus locally advanced at presentation . Non-horThe term 'carcinoid syndrome' is used to describe the hormonal manifestations of carcinoid tumours and occurs secondary to the secretion of serotonin, tachykinins, bradykinins and prostaglandins. Midgut carcinoid tumours are typically seen to secrete serotonin . Recent Investigation of these symptoms is best done with a multimodality approach including biochemical investigation, radiological and nuclear imaging, and finally histological confirmation where possible. In patients presenting with symptoms of carcinoid syndrome urinalysis can be carried out for elevated 5-HIAA levels. Chromogranin A can also be used as a sensitive marker to identify midgut carcinoid tumours, however, specificity may be low . The mosGiven that the majority of these tumours are well-differentiated, following an indolent course, prognosis is surprisingly unfavorable. This can mainly be attributed to the fact that the majority of cases present so late by which time spread has invariably occurred. Survival correlates closely to stage at presentation with a 5-year survival of 65% reported for localized/regional disease and 36% if distant metastases are present .The principal management approach in these cases is surgical resection of the primary lesion and is the only curative option. With smaller lesions < 1 cm) local resection is usually adequate. However, with lesions over 1.5 cm there is a high risk of recurrence and thus segmental resection is required with extensive clearance of the associated mesenteric lymph nodes  cm local.Further management of patients with liver metasteses is still controversial. Treatment options include resection of the hepatic tumours, or hepatic artery embolisation (HAE) as an alternative to surgery. There are a number of studies in the literature looking into the benefits of hepatic resection with regards to both symptomatic relief and prolonged survival rates. Que et al. report a 90% symptomatic response with liver resection and state that debulking extends survival; however recurrence is expected . Other aOther possibilities for symptomatic management of patients with hormonal symptoms include biotherapy using drugs such as somatostatin analogs. These have been shown not only to provide symptomatic improvement in 70–80% but also to stabilize tumour growth . This thDespite the rarity of this condition, carcinoid tumours are the most common lesion seen to affect the distal small intestine. Unfortunately, in the majority of cases presentation is often late in the disease and metastases are therefore regularly seen at the time of diagnosis. Analysis of five-year survival rates has identified several factors associated with a poor prognosis including multiple liver metasteses, the presence of carcinoid syndrome and high levels of hormonal markers . Given tWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The author declares that they have no competing interests.


Peritoneal encapsulation is a rare congenital anomaly characterised by a thin membrane of peritoneum encasing the small bowel to form an accessory peritoneal sac. We present a case of peritoneal encapsulation diagnosed incidentally in an 82 year old man undergoing laparotomy for colonic cancer. The sac was easily excised and surgery was otherwise uneventful. A discussion of the case and a review of the literature are presented. Peritoneal encapsulation (PE) is a very rare condition that is characterised by a thin membrane encasing the small bowel forming an accessory peritoneal sac. Cases usually present with small bowel obstruction or can be an incidental finding during laparotomy. We present a case of PE diagnosed during surgery for a colon cancer.An 82 year old white male presented to the out patient clinic complaining of left iliac fossa pain and was diagnosed with a descending colon cancer. He had never undergone abdominal surgery previously. The tumour was thought to be at risk of obstructing the colon and a potentially curative surgery was planned. During operation and after entering the peritoneal cavity the small bowel was entirely covered with a thin membrane that had the appearance of an accessory peritoneum through which the small bowels were visible (see figure th week of gestation [Peritoneal encapsulation is a very rare condition characterised by what looks to be an accessory peritoneal membrane covering all or part of the small bowels . This isestation , this caestation .The two commonest clinical presentations are: acute small bowel obstruction or incidental diagnosis during laparotomy for another condition , howeverDiagnosis of PE pre-operatively may be impossible because plain abdominal x-ray may be normal or only show dilated small bowel loop and CT scan findings can be very non-specific . MembranKnowledge of this congenital anomaly is of potential use to the abdominal surgeon, as its presence is not reported in standard anatomical descriptions. Its presence is a source of potential confusion, particularly in laparoscopic surgery after establishing pneumo peritoneum. The use of laparoscopy to carry out abdominal surgery is increasing, knowledge of this anatomical anomaly would allow a surgeon, who recognised the membrane as PE, to divide the membrane laparoscopically without recourse to conversion to open laparotomy.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.OA prepared the manuscript. ME carried out the literature search and edited the manuscript. JS conceived the idea to write the case report and edited the manuscript. All authors read and approved the manuscript.


We report a case of a 67-year-old Caucasian man with right upper quadrant abdominal pain. He underwent radiologic investigations that revealed a solid, focal mass, at the V hepatic segment. Because a definitive diagnosis, based on imaging appearance of the lesion, was impossible in our case, we performed a hystopathological investigation but the biopsies were inconclusive. So, the definitive diagnosis of intraductal papillary mucinous tumor of bile ducts was made on surgical resected material.Intraductal papillary neoplasm of the liver (IPNL) is a recently recognized entity which closely resembles an intraductal papillary mucinous tumor (IPMT) of the pancreas. Papillary tumors of the intrahepatic bile ducts are characterized by intraluminal growth, sometimes in papillary masses with bile duct obstruction and dilatation. Papillary tumors generally produce a large amount of mucin and so they may occasionally impede the flow of the bile juice and cause a severe ductal dilatation. Intraductal papillary neoplasm of the liver (IPNL) is a recently recognized entity frequently reported in association with hepatolithiasis and resembling intraductal papillary mucinous tumor (IPMT) of the pancreas, in terms of its histopathology, pathophysiology, and excessive mucin production -5.A 67-year-old Caucasian man underwent an ultrasound investigation because he suffered from right upper quadrant subcontinuous abdominal pain. The ultrasound examination and the successive Computed Tomography (CT)-examination, this last performed using an Aquilion 64 slice  revealed a solid, focal mass, about 3 cm in diameter, at the V hepatic segment in the presence of diffuse steatosis. On CT the mass presented hypodense respect to the surrounding tissue during the basal phase Figure  and withThe patient was admitted to the medical department of our hospital for further investigation. On admission, physical examination and laboratory findings were normal (included negative hepatitis B and C – biomarkers), showing only a mild increase of alpha-feto-protein (73 IU/mL).At this time, the patient underwent a upper abdominal Magnetic Resonance (MR) investigation, performed with a Eclipse 1.5 T  which showed the mass hypointense in T1 W unenhanced images and slightly dishomogeneous hyperintense in sequences with long TR. Figure The lesion suggested different diagnostic hypotheses, from a peripherical cholangiocarcinoma to a primitive degenerated mass characterized by an unusual dynamic pattern or a dysplastic nodule with focal hepatocellular carcinoma and this last diagnostic hypothesis was confirmed by contrast enhanced ultrasound (CEUS).Two different biopsies were performed using Biomol 21 G , one revealed inconclusive and the other showed only the presence of a micronodular cirrhosis that was regarded associated to non-alcoholic steatohepatitis.Finally, the patient was admitted to the surgical department of our hospital for the treatment.The mass was therefore excised by segmentectomy of the V hepatic segment, and after that the patient had an uneventful postoperative course.The liver lesion was 3 cm in the larger size; growing within a bile duct as a well demarcated large mass, no dilatation, stone or mucin were found in the large intrahepatic bile ducts around the lesion. Samples of the lesion were formalin fixed, paraffin embedded and stained with hematoxylin and eosin (H&E) and Alcian Blue and periodic acid Schiff stain (AB-PAS).Immunostaining for MUC1, MUC2, MUC5AC, MUC6, CDX2, CK-7, and CK-20 were performed on sections specimens that were dewaxed and rehydrated using Bio-clear  and graded alcohols. Endogenous peroxidase was blocked dipping sections in 3% aqueous hydrogen peroxide for 10' and antigen retrieval was performed with 10' microwave treatment in 10 mM citrate buffer, pH 6.00. The immunostaining was performed with the avidin-biotin-peroxidase complex technique using diaminobenzidine as chromogen. The sections were incubated overnight at 4°C with monoclonal antibodies against CDX2-88 (Biogenex) raised against a full-length CDX2 recombinant protein at 1:100 dilution, CK7  and CK20 . The apomucines were studied by using a mouse monoclonal antibodies against MUC-1 glycoprotein  at 1:100 dilution; MUC-2 glycoprotein  at 1:200 dilution; MUC-5AC glycoprotein  at 1:100 dilutionand MUC-6 glycoprotein  at 1:100 dilution. The neoplasm was made of papillary proliferation with thin fibrovascular stalk, covered by mild to moderate dysplastic epithelium, with tall columnar cells, mainly of mucinous type. A limited area of the tumor, showing an oncocitic pattern, was made of cuboidal cell with acidophilic, granular cytoplasm and prominent nucleoli. No goblet cells were found. Figure , 12The immunohistochemical test showed a diffuse CK7+/CK20- pattern of neoplastic cells. The apomucines MUC5AC and MUC6 were positive in more than 50% of neoplastic cells, indicating a gastric foveolar phenotype while CDX2 and MUC2 were negative, indicating that intestinal phenotype was completely absent; also MUC1 was negative. On the basis of these findings a diagnosis of borderline (gastric type) was made.The successive CT follow up examinations showed the patient free of the disease. Figure Intraductal papillary mucinous tumor of the bile ducts is characterized by innumerable frondlike infoldings of proliferated columnar epithelial cells and slender fibrovascular stalks that are supported by connective tissue from the lamina propria ,2. At hiPapillary cholangiocarcinoma rappresents 3–5% of the reported cholangiocarcinomas .Papillary adenocarcinoma is a low-grade malignancy that grows slowly and tends to spread along the mucosal surface and invading the ductal wall in the late phase of the development ,2,7.Papillomatosis represents a known condition where tumors are multiple and extend along bile ducts ,2.Intraductal papillary tumor produces a variable amount of mucin that may be retained in the lesion. Some tumors produce a large amount of mucin that is discharged into the bile ducts and may intermittently and partially impede the flow of bile juice, causing obstructive jaundice, sometimes complicated by cholangitis or stone formation. Endoscopy may show mucin draining from the papilla of Vater. This condition is diagnostic of a mucin-producing tumor of the bile or pancreatic ducts. When the mucin flow obstructs the duodenal papilla, both proximal and distal to the tumor bile ducts become diffusely dilated. So dilatation can be caused by the presence of the lesion as by the mucin excretion. Dilatation may affect only the segmental or lobar bile ducts or the entire biliary tree depending on the location of the cause. Moreover, the dilatation in bile ducts containing tumor may be disproportionate with that in the surrounding biliary tree ,2.The clinical manifestations are consisting in upper abdominal pain, episodic biliary pain, fever and jaundice. These symptoms are related to the recurrent obstruction of the bile ducts .The imaging techniques used for the study of papillary bile ducts neoplasms include ultrasonography (US), CT, endoscopic retrograde cholangiopancreatography (ERCP) and MR cholangiopancreatography that reveal bile ducts dilatation with or without visible intraductal papillary lesion ,2,8.Bile ducts that contain a mucinous intraductal papillary tumor may dilate diffusely or focally like an aneurysm and this presentation, such as the disproportionate lobar dilatation of the bile ducts where the tumor is localized than the ducts in the controlateral lobe, are considered a characteristic sign of the presence of an intraductal papillary mucinous tumor. So the involved bile ducts may dilate aneurysmlike, whereas others diffusely and proportionally ,2.Despite the study of Lim et al., where imaging techniques showed the presence of bile duct dilatation in all 15 patients, our case was not associated to bile duct dilatation, probably because the tumor was localized peripherically.At US papillary tumor can appear as an echogenic mass. The echogenicity is similar to that of the liver and there is no acoustic shadow. In our case, the lesion appeared hypoechogenic in the presence of surrounding steatosis. On CT the neoplasm presents as intraluminal soft-tissue mass enhancing or nonenhancing depending on whether the tumor is connected to the wall or not. When it is fixed, it shows confined within the ducts and preserves the bile ducts wall integrity. Moreover, the tumor can present as asymmetric enhanced thickening of the bile duct wall ,8. BesidYoon et al, describing the CT findings in 15 patients affected by malignant papillary neoplasms of intrahepatic bile ducts, reported that most of the tumors were hypo- or isoattenuating on contrast-enhanced CT. Conversely, CT could reveal an intraductal hypoattenuating mass associated with markedly dilated intra- and extrahepatic bile ducts in the three patients with mucin-hypersecreting papillary cholangiocarcinoma .In this case, the appearance of a mass showing hypovascular with the enhanced rim in later phases, suggesting the presence of a capsule, could invite to include the hepatocellular carcinoma with atypical features in the differential diagnosis. Early stages like a dysplastic nodule with focal degenerated areas was a inconsistent hypothesis because the focal hypervascular degenerated areas did not show in the arterial phase. The low attenuation of the lesion in the arterial and venous portal sequences and the elongated morphology, as in our case, could suggest the presence of a peripheral cholangiocarcinoma but, on the contrary, the late intralesional enhancement was poor . BecauseThe use of ERCP is recommended to detect the presence and the location of the suspected neoplasm and to reveal the presence and the quantity of mucin draining from duodenal papilla. Moreover, ERCP permits biopsy performation . This laOn ERCP the lesion appears as filling defect representing papillary tumor or as fine irregularities of the bile duct wall with a velvety or serrated contour.On US mucin is echo-free but may appear as a echogenic focus; on CT it is water-attenuating.Instead, ERCP may show small or large, elongated or amorphous filling defects caused by mucin presence in the dilated ducts.Various conditions present as filling defects in the dilated ducts and include air bubbles, stones, blood clots, and intraluminal tumors ,10,11.However, the papillary tumors of the bile ducts are characterized by the inconsistency and changeability of the imaging findings. Moreover, there can be differences between the radiologic and surgical presentation, and both these can differ from the pathologic findings but when intraductal masses are seen with localized dilatation of the intrahepatic bile ducts, papillary tumor of the bile ducts should be included in the differential diagnosis. Otherwise, the diagnosis may be made on the basis of histopathologic examination, as in our case ,8.IPNL: Intraductal papillary neoplasm of the liver; IPMT: Intraductal papillary mucinous tumor; CT: Computed Tomography; MR: Magnetic Resonance; CEUS: Contrast enhanced ultrasound; H&E: Hematoxylin and eosin; AB-PAS: Alcian Blue and periodic acid Schiff stain; US: Ultrasonography; ERCP: Endoscopic retrograde cholangiopancreatography;Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.GC, EG analyzed and interpreted the patient data and the radiologic investigations. RD, GD performed the hepatic segmentectomy. FS performed the histological examination of the resected specimen and was a major contributor in writing the manuscript. EB was a major contributor in writing the manuscript. TC was a contributor in writing the manuscript. CF revised the manuscript. All authors read and approved the final manuscript.


The uncinate process is a hook-like projection of the inferior aspect of the head of the pancreas. Carcinoma of the uncinate process of the pancreas is considered to be rare, difficult to diagnose and particularly devastating. The current method of detection is computed tomography. We report a case of carcinoma of the uncinate process of the pancreas in a patient who initially presented with deep vein thrombosis. The diagnosis of carcinoma of the uncinate process of the pancreas should be considered in patients who present with primary thromboembolic disease and other nonspecific signs. The head of the pancreas sits within the C-shaped curve of the duodenum. The uncinate process is an extension of the inferior part of the head of the pancreas that projects medially and wraps around the superior mesenteric vessels. Pancreatic carcinoma within the uncinate process appears to be rare, with previous reports describing an incidence of 2.5 percent (3 of 119 patients) [A 59-year-old British, Caucasian male presented with a one week history of left lower leg pain. The pain was associated with warmth and mild swelling. There was no history of trauma or prolonged immobility, and there was no associated chest pain. The patient reported a weight loss of 10 lbs over the previous 2 months, with anorexia over the previous month. He had been drinking 60 units of alcohol weekly for many years and was a life-long non-smoker. On physical examination, the patient was well hydrated and apyrexial. Cardiovascular examination revealed a systolic murmur. His abdomen was soft, non-tender with the splenic tip palpable in the left upper quadrant.Laboratory investigations revealed a raised D-dimer. In addition, there was an elevated C-reactive protein, erythrocyte sedimentation rate and white cell count. Vascular studies of the left leg demonstrated thrombus in the posterior tibial and peroneal veins below the knee and superficial thrombophlebitis in the long saphenous vein.The patient was admitted and treatment was commenced for his deep vein thrombosis. Echocardiography demonstrated calcific aortic stenosis and no valvular vegetations. During his admission, the patient developed a thrombus in a right brachial vein and his liver function tests became elevated. A subsequent ultrasound scan of the abdomen revealed multiple echogenic foci within the liver Figure . CT scanPatients with carcinoma of the uncinate process of the pancreas exhibit nonspecific symptoms with weight loss and upper abdominal pain as the most significant ones ,4. Impor4 and its specificity at 96 percent [In carcinoma of the uncinate process of the pancreas, CT scan is believed to be the best diagnostic tool ,4. Due t percent .Pancreatic carcinoma is regarded as a devastating disease. Due to the aforementioned nonspecific signs and early vascular involvement, malignancy of the uncinate process is particularly lethal. Birk et al were able to demonstrate that the median survival of carcinoma of the uncinate process was significantly lower than carcinomas affecting other areas in the head of the pancreas (5 months versus 11 months) .In our patient, venous thrombosis was the first manifestation of pancreatic carcinoma. The relationship between thromboembolic disease and pancreatic carcinoma was first described by Sproul in 1938 , and is Carcinoma of the uncinate process of the pancreas is a disease with a horrific prognosis. Furthermore, its nonspecific nature means that the diagnosis is often missed. Therefore, in patients presenting with primary thromboembolism and other nonspecific symptoms, carcinoma of the uncinate process of the pancreas must be considered. The CA19-9 level should be measured and if raised, a prompt CT scan should be performed.Written informed consent was obtained from the patient's next of kin for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.CS analysed and interpreted the radiological data regarding the diagnosis of carcinoma of the uncinate process of the pancreas. KS, EH, NV and SR were the major contributors in writing the manuscript. All authors read and approved the final manuscript.


An umbilical metastatic lesion is called 'Sister Mary Joseph's nodule'. It is an uncommon clinical or radiographic finding, and it is rare as the first sign of a malignant disease.We report three cases of Sister Mary Joseph's nodule. In the three cases presented, the primary tumor was an adenocarcinona of the sigmoid colon, a carcinoma of the bladder, and an adenocarcinoma of the gallbladder, respectively.The differential diagnosis of an umbilical lesion should always include metastatic disease apart from benign lesions and primary neoplasms. An umbilical lesion can be either benign or malignant. A malignant umbilical mass can represent a primary or metastatic lesion. The term 'Sister Mary Joseph's nodule' was first used by Sir Hamilton Bailey, in 1949 [A 62-year old man presented with a growing periumbilical mass and a mild lower abdominal pain during the last two months. He had symptoms of fatigue, and loss of weight and constipation alternating with diarrhea during the last six months. Patient was receiving medication for hypertension. On clinical examination there was a slight tenderness over the lower abdomen and an umbilical lesion fixed to the underlying tissues. Further evaluation, revealed anemia (Hct: 30%). Colonoscopy detected a tumor of the sigmoid colon. Computed tomography Figure  showed aA 64-year old female presented with haematuria and dysuria during the last 4 months. She had no other medical or surgical history. The assessment with ultrasound detected an established left hydronephrosis and a mass at the left lateral wall of the bladder protruding into its cavity. Cysteoscopic biopsy of the mass showed a transitional cell carcinoma. Further assessment with computed tomography (CT-scan) confirmed the presence of the tumor at the left lateral wall of the bladder, and revealed pelvic lymph nodes involvement and an umbilical mass measured 2 cm (Figure A 54-year old male presented with an umbilical painless mass. He was receiving medication for diabetes mellitus. Patient's physical examination revealed no other abnormality. Pathologic examination of percutaneous biopsy specimen showed malignant epithelial tumor, with characteristics of gall bladder or pancreatic origin adenocarcinoma. Neither upper gastrointestinal endoscopy nor colonoscopy detected any abnormality. Computed tomography of the abdomen showed a gall bladder with increased wall thickness and intraluminal invasive mass, peritoneal lesions, ascites, and an umbilical mass involving the adjacent adipose tissue Figure . PatientThe occurrence of Sister Mary Joseph's nodule is uncommon, and as first sign of malignancy is rare . The intAn umbilical mass can represent a benign lesion, such as a cyst or an abscess, but also a primary or metastatic malignant tumor. Although not common, the last two entities should be considered in the evaluation and management of the umbilical masses.The authors declare that they have no competing interests.AL contributed to the conception, design and drafting of the manuscript, as well as to the analysis and interpretation of data. DT contributed to the conception and design of the manuscript and revised it critically. KF contributed to acquisition of data and to the drafting of manuscript. AM contributed to acquisition of data and to the drafting of manuscript. VB contributed to acquisition of data and to the drafting of the manuscript. MT contributed to acquisition of data and to the drafting of the manuscript. SK contributed to the conception and design of the manuscript and revised it critically. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Melanosis refers to abnormal or excessive deposition of melanin pigment in the cells and/or tissue, which can be seen in any organ but commonly in skin and oral mucosa. Melanosis of the urinary bladder is an extremely rare benign condition and only a handful of cases been reported in the English literature before. In this article, we report a new case of urinary melanosis, describe the differential diagnostic features from pseudomelanosis and offer clues for correct diagnosis. We also provide comprehensive review of the literature on the subject. Melanosis refers to abnormal/excessive deposits of melanin in the cells and/or tissue. This condition can be seen in any organ but more frequently in the skin and oral mucosa. Melanosis of the urinary bladder is a very rare benign condition and only 6 cases have been reported in English literature thus far -4. Here,The patient is a 77 year-old African-American woman with medical history of urinary incontinence, large volume leakage, and severe urgency with leakage. She has been using diapers for the past two years. She was on Detrol LA for six months but no improvement of her symptoms. The patient was referred to our institution for further treatment. Under cystoscopy examination, clusters of punctuate dark spots were observed on the right lateral aspect of the bladder floor. There were no other lesions identified. Biopsies were obtained from the dark spots, and urine was sent for cytology. The patient had no previous cystoscopy examination or any other pigmented lesions on the skin or mucosal surfaces.The biopsy specimen consisted of multiple tan soft tissue bits ranging from 0.1 to 0.4 cm in greatest dimension. Microscopically, the sections showed benign urothelial mucosa with brown pigments focally present in the cytoplasm of urothelial cells. The pigments ranged from relatively light brown powdery to dark brown globules. The pigments were seen mainly in the cytoplasm and were partially or completely obscuring the nuclei. The underlying lamina propria showed mild congestion and acute inflammation with no pigment deposit Figure , while tUrinary melanosis is a very rare lesion and the exact incidence can not be determined. We reviewed all the available previously reported urothelial melanosis in the English literature. All patients in reported cases have some associated urinary symptoms such as, hematuria, difficulty voiding, or urinary incontinence. The age of the patients ranges from 43 to 86 years old and both sexes have been affected.Cystoscopically, brown to black pigmentation of the urinary bladder mucosa with flat or punctate patterns is usually observed. The pigmentation can be seen in any location of the bladder. There has been no description of associated mass lesions.Histologically, dark brown pigments are present mainly in the urothelial cells, but sometimes few pigment deposits are also seen in the lamina propria. The pigments are non-refractile, powdery and can form variable sized globules. The pigments are positive by Fontana Masson stain, and negative for PAS and Gomori's or Lillie's iron stains. The melanin pigment disappears after melanin bleach treatment. In one case, melanocytes were seen admixed with urothelial cells appreciated by S100 protein immunohistochemical stain, but not in the H&E sections . No nuclMelanin pigments should be differentiated from lipofuscin and hemosiderin deposits. Lipofuscin deposits are referred to as lipofuscinosis or pseudomelanosis in order to separate them from true melanosis (melanin deposits). Lipofuscin forms brown fine granules usually perinuclear located, representing undigested material from lipid peroxidation and associated with aging. It is positive by PAS stain, negative by Fontana Mason and iron stains, and does not disappear after bleaching procedure (bleaching resistant). Lipofuscinosis of the urinary bladder has been reported in a patient with interstitial cystitis after long term treatment with ciprofloxacin . The uriComparing to lipofuscin deposit in the urinary bladder, lipofusion deposit is more commonly encountered in the colonic biopsy specimen as melanosis coli and are usually associated with anthracene containing laxative or herbal remedies usage. The colonic mucosa usually shows brown discoloration under colonoscopy examination, and histologically, it shows pigmented macrophages in the lamina propria. The term of melanosis coli is misleading, because the pigments are not melanin at all . In thisHemosiderin is an intracellular storage form of iron that is produced by phagocytic digestion of hematin. They appear as a golden yellow-brown intracellular or extracellular pigment under light microscopic examination, and pigments are positive by Gomori's or other iron stains. The excessive iron storage in tissue is known as hemosiderosis. Hemosiderosis of urinary bladder was reported in a man with multiple blood transfusions as part of treatment for his anaplastic anemia. Cystoscopic examination showed a brown black 2.0 cm polypoid lesion on the right lateral wall and surrounding numerous smaller lesions of similar appearance. Histologically, the urothelial mucosa showed prominent hemosiderin deposits and hemosiderin-laden macrophages in the lamina propria with unremarkable urothelium . AlthougMost importantly, urinary melanosis needs to be differentiated from melanoma, which is also extremely rare in the urinary bladder, and classified as primary or metastatic, based on patient's clinical presentation and the presence or absence of atypical melanocytes in the urothelium . In the Patients with melanosis, lipofucinosis, hemosiderosis, or even melanoma of the urinary bladder, can have similar non-specific symptoms such as hematuria, cystitis, difficulty voiding, or urinary incontinence. Under the cystoscopic examination, all show pigmented lesions, although melanoma may have associated mass. Histological examination is the most important way to accurately classify the pigmented lesions in the urinary bladder.Melanosis of the skin or oral mucosa has been thoroughly studied because it is common. It can be seen in many conditions and is related to sun exposure (skin) or trauma (mucosa). It appears as gray or black macules. Histologically, it shows melanin deposits in the basal layer of the squamous epithelium. Melanosis of oral mucosa can also be seen in smokers and in patients with Peutz-Jeghers syndrome .Unlike melanosis of the skin and oral mucosa, the underlying etiology of urinary melanosis is not yet established. Since no melanocytes are normally present in the urothelium or metaplastic epithelium, melanocyte ectopia has been speculated for the primary melanoma of urinary bladder , which mUrinary melanosis is believed to be a benign lesion. Some author proposed melanosis vesica  for thisWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.BJ participated in conception of the idea, writing of the manuscript and interpretation histological slides. SYZ participated in interpretation histological slides. MH and CH participated in clinical data collection. HS participated in conception of the idea and interpretation histological slides.Summary of reported casesClick here for file


Haemangiomas are vascular lesions resulting from abnormal proliferation of blood vessels. They are the most common pediatric neoplasm. Kasabach-Merritt syndrome is a rare type of vascular lesion with peculiar characteristics. The diagnosis is based upon three basic findings; enlarging haemangioma, thrombocytopenia and consumption coagulopathy.A 5 month old boy was admitted to the Pediatrics department for the management of an abdominal wall mass. He was the first child of consanguineous parents, born in a private hospital following uncomplicated pregnancy and delivery. At birth a bluish birth mark 5 cm × 5 cm was noted below the umbilicus. Over the next five months, this birth mark increased in size and evolved into a swelling. As a result, the patient was admitted to Maternal and Child Health (MCH) unit for the management of this swelling.The clinical findings and imagining studies followed by laboratory investigations strongly suggested the diagnosis of Kasabach-Merritt syndrome.Vincristine was initiated after a trial of corticosteroids when the platelet count was 6000/cmm. One week after the start of vincristine the size of the lesion started to decrease. At the end of 6th week the lesion size decreased to half and the platelet count increased to 49,000/cmm. Vincristine was continued for another 2 weeks, no further improvement in lesion size or platelet count was observed. Vincristine was discontinued and the patient was shifted to the paediatric surgery department. A fresh platelet transfusion was given and the haemangioma was excised completely.The histopathological examination of the excised mass revealed a caverno-capillary haemangioma with infiltration into skeletal muscles.Six weeks treatment with vincristine in a dose of 0.5 mg/kg/week followed by surgical excision may be the best management in selected cases of Kasabach-Merritt syndrome. Haemangiomas are vascular lesions resulting from abnormal proliferation of blood vessels. They are the most common pediatric neoplasm. They have a special importance in clinical practice because of their distinct properties and behavior. Some haemangiomas are very small and hardly visible while others are large producing significant disfigurement . The manKasabach-Merritt syndrome is a rare type of vascular lesion with peculiar characteristics. The diagnosis is based upon three basic findings; enlarging haemangioma, thrombocytopenia and consumption coagulopathy. The thrombocytopenia and consumption coagulopathy is known as Kasabach-Merritt phenomenon . It is aA 5 month old boy was admitted to the Paediatric department for the management of an abdominal mass. He was the first child of consanguineous parents, born in a private hospital following uncomplicated pregnancy and delivery. At birth a bluish birth mark 5 cm × 5 cm was noted below the umbilicus figure . Over thInitial examination in the paediatric ward showed a playful child with normal development. His growth parameters were well within normal limits. The abdomen was distended below the umbilicus with obvious mass (12 cm × 7 cm) involving both inguinal and hypogastric areas. The mass was firm, non-tender, with indiscrete margins. The overlying skin was reddish-blue and smooth with no signs of inflammation. There was no visceromegaly. In addition skin at other areas and mucus membranes was normal. The examination of the central nervous system, cardiovascular system, and respiratory system was unremarkable.The initial Complete Blood Count (CBC) showed a haemoglobin level of 10.6 gm %, a white cell count of 8000/cmm, and a platelet count of 94,000/cmm. The relevant haematological investigations carried out during 14 weeks of the in-patient stay and thereafter in the out-patients' department are shown in Table During the hospital stay, the liver function tests and urine examination did not reveal any abnormality. An ultrasound of the abdomen showed a fluid collection in the subcutaneous tissue and muscle planes of anterior abdominal wall. Computed tomographic scan showed an extensive heterogeneous soft tissue density mass suggesting a haemangioma.The above clinical findings and imagining studies followed by laboratory investigations strongly suggested the diagnosis of Kasabach-Merritt syndrome.th week the lesion size decreased to half and platelet count increased to 49,000/cmm. Vincristine, in the same dose, was continued for another 2 weeks, no further improvement in lesion size or platelet count was observed. Vincristine was discontinued and the patient was shifted to the paediatric surgery department. A fresh platelet transfusion was given and the haemangioma was excised surgically completely  or liver (wedge resection/hepatectomy) ,12,13. TSix weeks treatment with vincristine in a dose of 0.5 mg/kg/week followed by surgical excision may be the best management in selected cases of Kasabach-Merritt syndrome.The authors declare that they have no competing interests.KA & HS carried out the patient diagnosis, investigation, chemotherapy, follow up, management of medical emergencies during surgery and provided medical care in the ICU, MK performed the surgery and removed the mass, AAAE general coordination, drafting of the manuscript, writing the final manuscript and provided important suggestionsAll authors read and approved the final manuscript.Written informed consent was obtained from the parents of our patient for publication of this case report and the accompanying images.


This report describes our experience with two cases that were ultimately diagnosed as retroperitoneal liposarcoma using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Case 1 is that of a 54-year-old woman with chief complaints of nausea and abdominal distention. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a large (15 cm diameter) tumor, which was significantly compressing the stomach and apparently occupied the entire left abdominal cavity. Although advanced primary gastrointestinal stromal tumor (GIST) or retroperitoneal tumor was inferred as the differential diagnosis, a definitive diagnosis was difficult using imaging alone. After EUS-FNA was done, the tumor was diagnosed histopathologically as high-grade liposarcoma. Case 2 is that of a 73-year-old man. Abdominal ultrasonography and CT showed a 6 cm diameter tumor within the pelvic cavity. The tumor had high MRI signal-intensity on both T1 and T2 images. Endorectal EUS showed a hyperechoic mass. The images suggested lipoma or liposarcoma containing lipoma-like components. Myxoid liposarcoma was revealed by subsequent EUS-FNA. Performing EUS-FNA was clinically useful for determining the subsequent therapeutic strategy in these cases where a tumor of unknown origin existed in the retroperitoneum. Endoscopic ultrasonography (EUS) is an important modality in the evaluati of luminal gastrointestinal diseases as well as diseases of the pancreas, gallbladder, and biliary ductal system. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been developed as a diagnostic tool using EUS . EUS-FNA Although liposarcoma is a malignant soft-tissue tumor that frequently occurs in extremities and retroperitoneum , it repoA 54-year-old woman who suffered from nausea and abdominal distention had consulted with her family doctor. She had no previous history of a related disease or these symptoms. Esophago-gastro-duodenoscopy (EGD) showed a subepithelial mass on the upper gastric corpus; an abdominal CT showed a huge tumor as a low-density mass occupying most of the left side of the abdominal cavity . She wasA 73-year-old man who showed a retroperitoneal mass on abdominal ultrasonography for health screening visited our hospital for further examination. Results of CT showed a 6 cm diameter low-density tumor within the pelvis . AbdominLiposarcoma is a kind of sarcoma that preferentially develops in the extremities (40%), retroperitoneal space (19%), and groin (12%), accounting for 9.8–16% of all sarcomas –7; with Histopathologic classification of liposarcomas was proposed by WHO classification  in 1969,As for treatment of liposarcomas, surgical therapy is the first option in resectable cases. Retroperitoneal liposarcoma has few clinical symptoms. Therefore, it often infiltrates into the surrounding organs. Consequently, the local recurrence rate is as high as 60% at five years. Decreasing the risk of recurrence requires en bloc excision including as much surrounding tissue as possible to prevent remnant tumor tissue , 13. ForEUS guided FNA has been applied for cytopathological diagnosis of a variety of lesions within and outside the gastrointestinal tract. Although there is a case of pancreatic metastasis of liposarcoma diagnosed by EUS-FNA , to our


Primary lymphoma of the colon is a rare tumor of the gastrointestinal (GI) tract and comprises only 0.2-1.2% of all colonic malignancies. The most common variety of colonic lymphoma is non-Hodgkin's lymphoma (NHL). The GI tract is the most frequently involved site, accounting for 30-40% of all extra nodal lymphomas, approximately 4-20% of which are NHL. The stomach is the most common location of GI lymphomas, followed by the small intestine. Early diagnosis may prevent intestinal perforation; however, the diagnosis is often delayed in most cases. Therapeutic approaches described in two subsets include: Radical tumor resection (hemicolectomy) plus multi-agent chemotherapy (polychemotherapy) in early stage patients, biopsy plus multidrug chemotherapy in advanced stage patients. Radiotherapy is reserved for specific cases; surgery alone can be considered as an adequate treatment for patients with low-grade NHL disease that does not infiltrate beyond the sub mucosa. Although resection plays an important role in the local control of the disease and in preventing bleeding and/or perforation, it rarely eradicates the lymphoma by itself. Those with limited stage disease may enjoy prolonged survival when treated with aggressive chemotherapy. Primary lymphoma of the colon is a rare tumor of the gastrointestinal (GI) tract and it comprises only 0.2-1.2% of all colonic malignancies.1 The stom2st h. Sputum was negative for acid-fast bacilli (AFB). A peripheral smear showed i) microcytic to normocytic, hypochromic RBCs, ii) mild anisopoikilocytosis of RBCs, iii) a total WBC count and cell distribution within the normal range, iv) adequate number of platelets. Stool was negative for occult blood. Liver function tests (LFTs) including levels of liver enzymes, serum bilirubin, serum proteins, and alkaline phospatase were within normal limits. Bone marrow biopsy revealed no abnormalities; a chest X-ray was also normal. Abdominal ultrasonography (USG) detected a hypoechoic mass with pseudo-kidney signs suggestive of a bowel mass noted in the left hypochondrium, measuring about 9 × 6 cm with bowel wall thickening, and a possibility of carcinoma of the left colon. A barium enema study depicted a circumferential growth involving the proximal part of the descending colon, producing a long segment stricture with mucosal irregularity and shouldering, suggestive of malignant growth but with a normal Ileocecal junction. Colonoscopy and biopsy were inconclusive.A 45 year-old male patient presented with dull-aching abdominal pain and a lump in the left flank of three months' duration. He showed loss of appetite and weight, and altered bowel habits. A general physical examination revealed that the patient was anemic. Abdominal examination revealed a tender, firm, irregular mass of 9 × 6 cm in the left hypochondrium and left lumbar region with restricted intrinsic mobility and no movement with respiration. Rectal examination did not reveal any abnormalities. His routine blood investigations were normal except hemoglobin which was 8.6g% and ESR which was 46 mm/1The patient was subjected to laparotomy through an infraumbilical midline incision . This revealed a huge growth at the splenic flexure and proximal descending colon with lymph nodes at the origin of the inferior mesenteric artery. There was no ascitis and detectable secondary deposits in the pelvis, liver, spleen, or peritoneum. Left hemicolectomy was performed with transverse-sigmoid, end-to-end anastomosis. Histopathological investigation revealed diffuse, large cell type, intermediate grade NHL of the left colon. The resected margins were free of tumor but the lymph nodes showed reactive hyperplasia. The postoperative period was uneventful and the patient received six cycles of chemotherapy following surgery (CHOP regimen). The patient was on regular follow-up for two years without any recurrence.st h. Sputum was negative for AFB and showed no malignant cells. Results of other blood investigations including assays for liver function tests were within normal limits. A peripheral smear revealed microcytic, hypochromic anemia and a chest X-ray showed features of chronic bronchitis. Bone marrow biopsy revealed no abnormality but abdominal USG detected multiple bowel masses with lymphadenopathy in RIF. A barium enema study revealed cecal narrowing, mucosal irregularity, shouldering, and a normal Ileo-cecal junction. USG-guided FNAC of the mass suggested the possibility of lymphoma, which was confirmed by colonoscopy and biopsy.A 60 year-old male patient presented with dull-aching, abdominal pain and a lump in the right lower abdomen of four months' duration. He showed loss of appetite and weight, an evening rise of temperature, and altered bowel habits. He had a cough with hemoptysis for four days. A general physical examination revealed clubbing and anemia. Abdominal examination revealed a tender, soft, irregular, freely mobile mass of 7 × 4 cm size in the right iliac fossa (RIF). Rectal examination results were normal. The patient's routine blood investigations were normal except hemoglobin which was 6.3 g%, and ESR which was 90 mm/1The patient was subjected to laparotomy through an infraumbilical midline incision which revealed a fleshy growth arising from the cecal wall with lymph nodes in the mesentery. There were no detectable secondary deposits in the liver, spleen, pelvis, or peritoneum. Right hemicolectomy  was perfLymphomas of the GI tract are the most common type of primary extranodal lymphomas, accounting for 5-10% of all non-Hodgkin's lymphomas. In particular, primary intestinal lymphomas represent about 15-20% of GI lymphomas. Primary 12Intestinal lymphomas differ from gastric lymphomas not only in pathology, but also in their clinical features, treatment, and prognosis.78 The gr73339The most common symptoms of colonic lymphoma are abdominal pain, nausea, vomiting, weight loss, abdominal mass, change in bowel habits, hematochezia,3 obstruc21123Abdominal ultrasonography, colonoscopy with sub mucosal biopsy,3 and comCombined modality of approach that includes surgical debulking and systemic chemotherapy is the preferred treatment. Differen232However, it is still thought that the prognosis of intestinal lymphomas is related to surgery; therefore, it seems appropriate and cautious to resect intestinal lymphomas whenever possible.15 Those et al,[n = 1) and small lymphocytic (n = 1). Eleven patients underwent hemicolectomy: Right-sided in nine and left- sided in two; five diffuse large B-cell lymphoma patients required emergency surgery for intestinal perforation.In their study of NHL of the colon, Bairey et al, found thPrimary colonic lymphomas are rare; the cecum is the most common site of occurrence. Early diagnosis may prevent intestinal perforation; however, the diagnosis is often delayed in most cases. Surgical resection is the mainstay of treatment for localized primary lymphomas, followed by postoperative chemotherapy. Those with limited stage disease may enjoy prolonged survival when treated with aggressive chemotherapy. Surgery alone can be considered as an adequate treatment for patients with low-grade NHL disease that does not infiltrate beyond the sub mucosa. Although resection plays an important role in the local control of the disease and in preventing bleeding and/or perforation, it rarely eradicates the lymphoma by itself.


The drainage of abdominal cavity by means of tube drains is the oldest method. The herniation of gallbladder through the abdominal wall is very rare. Although there are studies informing evisceration of organs such as small intestines and ovary from drain site; at the literature scanning, no publication has been met with advising gallbladder evisceration from the Pezzer drain site so far.th postoperative day. One day after the discharge, applied to another general surgery center, by complaining that the intestine protruded through an opening in its surrounding walls of the drain place and that has been gradually enlarged. During the operation it was determined that proximal 2/3 of gallbladder has been protruded to outside of abdomen. Cholecystectomy was performed, and patient recovery was uneventful.We describe here the first case in the literature of gallbladder evisceration from the Pezzer drain site. A male case with a history of operated incarcerated right inguinal hernia presented with a surgical abdomen. With a diagnosis of intestinal ischemia, the patient underwent laparotomy. About 200 cc fluid with serous quality has been determined in the abdomen and aspirated. Patchy ischemia zones were observed in ileum, over serous face. No. 30 Pezzer’s drain was placed for the intention of drainage, extending from the right side of navel towards rectovesical area. After the drainage stopped patient was discharged from hospital with recovery on the 8Gallbladder herniation is a pathology requires emergency operation. Drainage is a method which is used to prevent noxious materials from building up in the abdominal cavity. Application of drains has been known for more than 2000 years. Recently, parallel to the developments in surgical techniques and technological advances, surgical abdominal procedures have become safer with less postoperative complications. Draining abdominal cavity by drainage tubes is the oldest method . HoweverWhile there are studies that report evisceration of organs such as small intestine and ovary at the site of a drain, no study which involved evisceration of a gallbladder at the site of a pezzer drain, has been found in the literature ,5.The aim of the present study was to evaluate our patient who experienced evisceration of gallbladder at the site of a Pezzer drain, which is believed to be the first case in the literature, in light of the related literature data.A 56-year-old Turkish male patient had been diagnosed with incarcerated inguinal hernia after presenting to a different general surgery center due to swelling in the right groin. Because of the anesthesiologist’s decision to evaluate him as ASA E due to pulmonary problems, he had been operated under local anesthesia. Perioperatively, ischemic alterations had been observed in the incarcerated small intestine loop. Intestinal viability had not been evaluated completely. Monitoring of the patient had been decided prior to application of resection, and following the reduction of the intestinal loop back into the abdomen, herniography had been applied with propylene mesh. The case had been referred to the Emergency Surgery Department of our teaching and research hospital due to development of abdominal distension, presence of air-fluid levels on erect abdominal direct radiographs (EADR), and absence of gas-feces expulsion during the post-operative period. We evaluated the patient in Emergency Service. Laboratory results showed normal CBC values. Biochemical parameters were as follows: CK : 794 U/L (0-270), AST : 72 U/L (0-38), LDH : 555 U/L (240-480), Ca : 7.2 mg/dl (8.4-10.3). EADR of the patient displayed air-fluid levels on the abdomen. Abdominal ultrasonography (US) showed considerably dilated intestinal loops, intestinal content moving to and fro, and grade 2 bilateral renal parenchymal disease.Laparotomy was performed due to consideration of intestinal ischemia. Serous fluid of an amount of 200 cc was found in the abdomen and aspirated. Serosal surface of the ileum exhibited ischemic areas in patches. Lembert 3.0 silk sutures were applied to those areas. Pezzer drain (No. 30) was placed from the right portion of the abdomen extending through rectovesical site. Feces evacuation was observed on the postoperative 3rd day. After reaching the amount of 20 cc drainage, the drain was removed on the postoperative 5th day. Following removal of the drain, around 20-30 cc serous discharge was observed daily from the drain site. Abdominal distension was present until the postoperative 6th day. The case which had shown expulsion of gas and feces, exhibited a reduction in distension followed by total resolution. The case showed no discharge from the drain site on postoperative 8th day and discharged in good health. One day after the discharge, our patient applied to another healthcare center with the complaint of a herniated intestine from his drain site which gets larger by time. He was referred to our clinic from this center with the prediagnosis of intestinal herniation. Initial evaluation in Emergency Service revealed absence of evacuation of feces and gas. The EADR taken showed gas accumulation but no fluid-air levels. A tissue of 5 × 4 × 3 cm, which was irreducible, edematous, and appearing like ischemic and similar to an intestinal loop, was determined to be protruding from the drain site . He was According to the search we performed in the medical literature, evisceration of gallbladder at the site of a drain, is the first case in whole medical literature. Moreover, there was only one case of incisional hernia including gallbladder herniation which was reported by Benzoni et al. . Garcia It is contentious if this case should be identified as an evisceration or an incisional herniation. While several authors describe protruding of intraabdominal organs out of the abdomen as evisceration, some call it as hernia ,12. EvisIn such cases, the first thing one would suggest as the underlying etiology, may be hypermobile gallbladder attached to the liver by mesentery or a gallbladder longer than normal. Hypermobile gallbladders attached to the liver by a long mesentery, create a predisposition for torsion and incarceration. In the literature, while there has been one case exhibiting incarcerated gallbladder in ventral hernia , anotherAnother possible factor may be the large drain site. A case showing small intestine evisceration has been reported in the literature . HoweverIncreased intraabdominal pressure may be another underlying cause of gallbladder evisceration . Our casThe reason behind confusion in preoperative diagnosis, was the absence of a case with a gall bladder evisceration at the site of the drain in the literature, and similarity of the morphologic appearance of edematous and ischemic gallbladder wall and edematous and ischemic small intestine wall. The intense gas accumulation was evaluated as an early period sign of intestinal herniation which caused confusion in preoperative hollow organ injury diagnosis. Immediate surgical intervention bears importance in such cases due to possible strangulation incidents.While gallbladder herniation is a serious pathology similar to intestinal herniation which requires immediate intervention, correct preoperative diagnosis can make a difference in the preferred treatment option such as deciding to employ laparoscopic cholecystectomy.


Pneumoperitoneum frequently indicates a perforated abdominal viscus that requires emergent surgical management. However; pneumoperitoneum, on rare occasion, can occur without perforation. In these cases, it is defined as benign pneumoperitoneum. Benign pneumoperitoneum means asymptomatic free intra-abdominal air or pneumoperitoneum without peritonitis and can occur occasionally with colonoscopy. In this paper, we present a rare case of benign pneumoperitoneum that developed after diagnostic colonoscopy and review it in conjunction with the current literature. Colonoscopy is a safe procedure with a low incidence of complication . ColonicWe present and review this case in conjunction with the current literature because of its rarity and controversial treatment options.A 70-year-old male patient was admitted to emergency service with complaint of abdominal pain. He had a history of diagnostic colonoscopy performed 2 days before. Colonoscopy was a diagnostic procedure for evaluation of his complaints of right lower quadrant pain and constipation. Gastroenterologist that had performed the procedure indicated that the colonoscopic procedure was not complex and was performed safely. Room air was used for inflating the colon. Abdominal complaints of the patient started after colonoscopy and increased significantly. Abdominal pain, distention, and rigidity were detected on physical examination.3, Hb: 12 gr/dL, Hct: 35.4%, and CRP > 96 mg/L, fever: 37.8°C. Free air was detected on the plain films of the abdomen ( Laboratory findings were as follows: Leukocytes: 12000/mm abdomen . On the  abdomen . There wThe patient went under emergent operation. During the exploration, no perforation was detected in the gastrointestinal system. The mass in right iliac fossa was so fixed to the adjacent structures that, we could not remove this mass. The mass next to left iliac vein was unrelated to any organ in pelvis and it was removed completely. Abdomen was closed in layers. The postoperative course was uneventful. After the discharge of gas and stool, oral feeding was started in the postoperative 3rd day. No free air was seen in the plain film of the abdomen taken on postoperative 7th day and the patient was discharged from the hospital in health. The pathologic diagnosis of the mass was lymph node metastasis of adenocarcinoma. The result of the prostate biopsy taken in conjunction with transrectal ultrasonography was also adenocarcinoma. Upon these results, the patient was sent to medical oncology department for advanced treatment. Control tomography after oncologic treatment has not been performed yet.Colonoscopy is a safe procedure with a low incidence of complications and has great impact on diagnosis and management of diseases of the colon and rectum , 10. ColPneumoperitoneum frequently indicates a perforated abdominal viscus that requires emergent surgical management because of visceral perforation in 85% to 95% of all cases . Five toBP is defined as asymptomatic free intra-abdominal air or pneumoperitoneum without peritonitis and appears as a characteristic radiolucency seen below the diaphragm on chest radiograph or in superiorly dependent location on abdominal radiograph , 7. BP hRare studies have prospectively investigated BP after colonoscopy , 11. ThePneumoperitoneum detected after colonoscopy may pose a management dilemma , 8. Ther2 may cause BP, this cannot be the reason of BP in our case; because we used room air for inflating colon during colonoscopy procedure.Although inflation of colon with COOur patient had peritonitis and we performed laparotomy but there was no visible perforation. So, we decided that the reason of intraabdominal free air was transmural passage of air or microperforation, not a perforation. Then, we thought that the cause of peritonitis might be an intraabdominal tumor or metastasis. On exploration we found a mass next to the left iliac vein. Therefore, it should be kept in mind that some cases without perforation may be misdiagnosed as peritonitis. So, before the operation other factors which can cause pain and leukocytosis should be considered carefully.In conclusion, the optimal treatment of pneumoperitoneum after colonoscopy, whether conservative or operative, is still unclear . Until a


Polymyalgia rheumatica is an increasingly common disease in older people, which gives rise to arthralgia and is mainly treated with corticosteroids. Patients in this age group also have a higher incidence of other co-morbidities including colonic pathology. Corticosteroid usage may mask signs of sepsis or complications secondary to intra-abdominal pathology, thereby delaying diagnosis and treatment, with eventual adverse outcome. These two cases highlight the importance of awareness and prompt recognition of this condition in order to avoid significant morbidity and mortality.A 73-year-old Caucasian woman with a diagnosis of polymyalgia presented with symptoms of an exacerbation in her right hip joint. Despite standard therapy with corticosteroids she failed to improve and started to develop features of widespread sepsis. Specific questioning revealed that, at the very onset of her symptoms, she had experienced mild diarrheal symptoms. Investigations revealed perforated diverticular disease with a peri-femoral abscess.A 69-year-old Caucasian woman with polymyalgia presented with left thigh pain and weakness associated with weight loss. A diagnosis of exacerbation of polymyalgia rheumatica was made and she was treated with corticosteroid therapy. Shortly afterwards she was admitted with generalized peritonitis. Laparotomy revealed a retroperitoneal abscess secondary to a perforated sigmoid colonic tumor.Patients with polymyalgia may have perforated colonic diverticular disease which mimics their rheumatic pathology. In such cases steroid therapy, which is the mainstay of polymyalgia therapy, can be detrimental. Primary and hospital practitioners are encouraged to be vigilant regarding non-specific gastrointestinal symptoms and consider alternative diagnoses in those patients whose symptoms do not resolve with standard therapy, as this can lead to an overall better outcome. Polymyalgia rheumatica (PMR) is one of the most common chronic inflammatory conditions in elderly individuals . The dis9/dL, neutrophils 18.36, C-reactive protein (CRP) 279 mg/L and her body mass index (BMI) was 27 kg/m2. Hip, pelvic, chest and abdominal X-rays, ultrasound scan of the abdomen, pelvis and stool cultures were unremarkable. Sigmoidoscopy revealed mild active proctitis and diverticulosis. A diagnosis of exacerbation of PMR was made and corticosteroid dosage increased to 40 mg daily. In view of raised inflammatory markers, intravenous broad spectrum antibiotics were also commenced (Tazocin (piperacillin and tazobactam) and gentamicin). Despite this her limb weakness and hip pain became progressively worse and inflammatory markers continued to rise. Magnetic resonance imaging (MRI) of the spine and pelvis was therefore arranged on day five of admission. This revealed a posterior diverticular perforation into the pre-sacral space resulting in large bilateral gluteal abscesses. There was also gas extending around the right femoral head  had been commenced three weeks prior to admission, she had failed to improve and therefore in-patient assessment was sought. Her past medical history consisted of hypertension and two successful normal vaginal deliveries. There was no significant family history. Apart from prednisolone, her only other medication was bendrofluazide 2.5 mg once daily. On admission to hospital, examination revealed reduced right hip and knee power of 4/5. Her diarrhea had settled by the time of admission to hospital. She was apyrexial, with a white cell count of 22.6×102. Her past medical history was unremarkable apart from known polymyalgia and she had had one previous normal vaginal delivery. There was no significant family history. She was normally on 10 mg of prednisolone daily. She was on no other medication. Mild weakness of left hip flexion was noted and a white cell count 19.6×109/dL, CRP 230 mg/L.A 69-year-old Caucasian woman with PMR presented to her general practitioner with a three-week history of left thigh pain. She also had left-sided abdominal pains for six months, which were treated with paracetamol 1 g and mebeverine 135 mg as required. Her bowels usually alternated between constipation and diarrhea with no recent change or rectal bleeding. She had reduced appetite and weight loss of 3 kg over three months. BMI was 20 kg/mA diagnosis of exacerbation of PMR was made and her steroid dose increased to 30 mg daily. She was admitted a week later with severe abdominal pain, tachycardia and a fever of 38°C. Abdominal examination confirmed generalized peritonitis.Laparotomy revealed fecal peritonitis and a large retroperitoneal abscess due to an obstructing proximal sigmoid tumor with perforation. She underwent a Hartmann's procedure followed by a further laparotomy for a residual retroperitoneal abscess Figure . TazocinPatients with polymyalgia may have perforated colonic or purulent diverticular disease which mimics their rheumatic pathology. In such cases steroid therapy which is the mainstay of polymyalgia therapy can be detrimental . AlthougThese two cases highlight the importance of paying close attention to abdominal symptoms that cannot be attributed to polymyalgia and the need to exclude a primary intra-abdominal pathology first. Abdominal X-rays, ultrasound and sigmoidoscopy may be misleading and therefore if patients fail to improve, prompt imaging with CT/MRI is recommended in order to initiate appropriate therapy before patients become too unstable to receive treatment ,7.Case 1 highlights how plain film imaging may fail to detect perforations due to the absence of significant pneumoperitoneum.BMI: body mass index; CRP: C-reactive protein; CT: computed tomography; MRI: magnetic resonance imaging; PMR: polymyalgia rheumatica.Written informed consent was obtained from the relatives of the patient in Case 1 for publication of this case report and accompanying images. A copy of the written consent is available for review by the journal's Editor-in-Chief. Written informed consent could not be obtained from patient 2 because the patient is now deceased and we were unable to contact a next of kin despite reasonable attempts. Every effort has been made to protect the identity of the patient and there is no reason to believe that the family would object to publication.The authors declare that there is no conflict of interest. No funding was sought or received for this report.The authors declare that they have no competing interests.PdeS was involved in the management of Case 1, and was involved in conception of the case reports, data acquisition, literature review, writing the article and critical revision. GV was involved in management of the cases, conception and critical revision. NP was involved in the management of Case 2, data acquisition and critical revision. All authors read and approved the final manuscript.