The term ¨Lemmel Syndrome¨ is used to describe obstructive jaundice that is secondary to periampullary duodenal diverticula (PDD) in the absence of choledocholithiasis or neoplasia. PDD is found in 22% of the population. According to our knowledge, only two cases of Lemmel syndrome have been reported in Mexico. We report two cases of Lemmel syndrome in a 94-year-old and a 71-year-old woman who presented with clinical jaundice. One of the cases was treated with endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy, balloon sweep, and the placement of a plastic biliary prosthesis, and the other with laparoscopic biliodigestive bypass and a manual lateral end choledocho-duodenal anastomosis. Our objective is to expand the information on this rare pathology to take it into account as a diagnostic possibility of jaundice and to define appropriate management, which can be endoscopic or surgical. Lemmel syndrome (LS) was first described by Dr. Gerhard Lemmel in 1934  and is dClinical case 1A 94-year-old woman has undergone an open cholecystectomy and arterial hypertension treated with captopril as part of her important medical history. She presented to the emergency department for medical evaluation, complaining of localized pain in the epigastrium after four days of evolution, associated with nausea, vomiting of gastro-alimentary content on multiple occasions, fever, jaundice, and choluria.Upon physical examination, there was mucocutaneous jaundice. Abdominal tenderness in the mesogastrium, without visceral or palpable masses. Vital signs were a blood pressure of 128/85 mmHg, a heart rate of 74 bpm, a respiratory rate of 19 bpm, SaO2 of 98%, and a temperature of 37.6ºC. Her blood workup results are shown in Table An abdominal ultrasound was requested as part of the diagnostic work-up, and the findings were: the common bile duct was 1.1 cm, the pancreas had inflammatory data, the gallbladder was surgically absent, and the portal vein was 1.6 cm.The patient was admitted to the general surgery department with a diagnosis of moderate-severe acute cholangitis and acute pancreatitis. Cholangiography and magnetic resonance cholangiopancreatography (MRCP) was requested as part of the diagnostic approach Figures , 2, showClinical case 2A 71-year-old woman, whom, as part of her important medical history, she refers to as having been diabetic and having hypothyroidism. She was hospitalized due to cholangitis and choledocholithiasis, and an ERCP was performed, reporting unresolved choledocholithiasis, so stent placement was performed. One month later, the patient was readmitted with moderate acute cholangitis, for which a new ERCP was performed. During the new ERCP, an Amsterdam biliary prosthesis of 7 Fr x 10 cm was placed due to a previously migrated biliary prosthesis. Following this, balloon sweeping with gallstone extraction and laparoscopic cholecystectomy was performed.She returned to the emergency room of our hospital seven months later, reporting abdominal pain localized in the epigastrium, abdominal distension, nausea, and subjective fever, predominantly in the evening, for four days. Vital signs were blood pressure at 126/82 mmHg, heart rate at 72 bpm, respiratory rate at 17 bpm, SaO2 at 96%, and temperature at 36.9ºC. Physical examination revealed scleral icterus staining, a painful abdomen on palpation in the epigastrium and right hypochondrium, without visceromegaly or palpable masses, and no evidence of peritoneal irritation.Her blood workup results were as shown in Table A new ERCP was performed where Vater's ampulla was identified with data from previous sphincterotomies, as well as juxtapapillary diverticulum, biliary prosthesis migrated to the right hepatic duct, dilated intrahepatic biliary tract, common hepatic duct of 16.3 mm, and permeable cystic duct, so a biliary endoprosthesis was placed and a balloon sweep was performed. A laparoscopic biliodigestive bypass and a manual lateral end choledocho-duodenal anastomosis were scheduled for her  is very low in the general population. In Mexico, only two cases of Lemmel syndrome (LS) have been reported ,6. PDDs The objectives of the treatment of LS are to decrease pancreato-biliary complications secondary to bile duct obstruction . ConservWhen endoscopic or conservative treatment fails, surgical treatment is usually reserved . EndoscoThe biliodigestive bypass procedure is easy to perform and is associated with morbidity of 1% to 8% and mortality of less than 6%, which are lower than diverticulectomy. The biliodigestive bypass is an effective treatment for additional symptoms in most cases, but the patient remains at risk for recurrent pancreatitis as the bypass does not treat the sphincter dysfunction caused by the impingement of the diverticulum on the pancreatic duct. The laterolateral choledochoduodenostomy is the simplest and quickest procedure, especially in adults with multiple comorbidities .As a cause of biliary obstruction, Lemmel syndrome is a very rare clinical entity. Therefore, it is important to consider it as a differential diagnosis for proper management. The treatment of a patient with symptomatic Lemmel syndrome can be either endoscopic or surgical and is based on the clinical characteristics of the patient and the outcome of in-hospital management.


Extracardiac rhabdomyomas are rare benign mesenchymal tumors diagnosed upon radiological and hystologic investigations and the treatment of choice is surgical exertion. There aren’t any similar cases managed conservatively reported in literature as in our case, to the best of our knowledge. We present a rare case of fetal cheek rhabdomyoma diagnosed in a healthy 2 months-old boy, with asymptomatic mass over the left masseter. The lesion could not be removed, due to the size and dimensions and the young age of the patient. However, the lesion did not show signs of spreading or progression over a 36 months follow-up. Fetal rhabdomyoma is a benign tumor, often located in the head and neck district, where surgery, especially in very young children, is associated with a high risk of complications and long-term sequelae. Our case report demonstrates the possibility to manage these lesions conservatively in the first years of life with close sonographic and clinical follow-up. Rhabdomyomas are rare benign tumors arising from the striated muscle and cardiac rhabdomyomas account for the most common type. The extracardiac rhabdomyomas account for less than 2% of all neoplasm showing striated muscle differentiation and 70 to 90% of all extracardiac rhabdomyomas occur in the head and neck area ,2. ThoseA healthy 2 months-old boy, without significant family history, presented to our clinic with a newly noted mass over the left cheek over the masseter area .The mass was firm, partially mobile, cold, and apparently painless, with a diameter of around 2 cm. The lesion did not impair neck rotation and lateral movements, neither caused forced head position or tilting. An ultrasound study was performed and showed a fusiform mass over the left masseter muscle, which appeared inhomogeneous and hypoechogenic, sized 17 mm × 15 mm. The mastoid extremity of the homolateral sternocleidomastoid muscle (SCM) was also noted to be thickened (8 mm) .A Magnetic Resonance imaging (MRI) of the soft tissues was performed and showed an enlargement in the context of the left masseter muscle (20 mm × 15 mm × 21 mm). The lesion appeared minimally hyperintense in T2 sequences and isointense in T1 sequences with negative contrast enhancement. The MRI study confirmed a thickened proximal SCM (13 mm × 14 mm × 31 mm), as shown in Further ultrasound studies were performed in the following months and showed rapid mass growth (around 10 mm over 2 months). Hence, in view of the growth rate and in order to confirm the nature of the lesion, a punch biopsy was performed. The pathology report showed morphological and immunohistochemical characteristics of fetal rhabdomyoma, intermediate type. Microscopic description of histological examination was: Proliferation predominantly cellular, composed partly of fused cells with abundant eosinophilic cytoplasm, and partly of round cells with a decentered nucleus and intensely eosinophilic, roundish cytoplasm, suggestive of rhabdomyoblasts. Small oval or fused nuclei without atypia. No evidence of necrosis or pleomorphism. No evidence of mitosis. On immunohistochemical examination, the neoplastic population was diffusely positive for Myogenin, Myo-d1, desmin, muscle-specific Actin, and negative for smooth muscle Actin, myosin, CD34. Proliferation fraction assessed with Ki67 antibody was 2%.A total excision of the tumor was deemed not feasible, because of the size and location of the mass alongside the young age of the patient. Conversely, it was discussed and agreed with the boy’s family a close follow-up, with period clinical and ultrasound sonographic (USS) assessments. The ultrasounds performed at 12, 24, and 36 months showed an unchanged tumor size without any signs of spreading or progression despite the kid’s growth .Rhabdomyomas are rare benign mesenchymal tumors with skeletal muscle differentiation. Unlike most other soft tissue tumors, rhabdomyomas are strikingly outnumbered by their malignant counterpart (rhabdomyosarcomas), and they account only for 2% of all tumors with striated muscle differentiation . They arBoth adult and fetal rhabdomyoma affect mostly the head and neck area (90% of cases), such as the parapharyngeal space, salivary glands, larynx, mouth, and neck soft tissue. Uncommon locations for adult and fetal rhabdomyoma include the mediastinum or the chest for the former and abdomen and extremities for the latter. Both types usually have a slow growth rate, but some may present a faster growth pace, causing symptoms such as hoarseness, airway obstruction, dysphagia, and decreased vision. The myxoid type of fetal rhabdomyomas (classic type) is composed of spindle-shaped or primitive oval immature skeletal muscle fibers with abundant myxoid backgrounds. Conversely, the juvenile (intermediate) type shows less myxoid matrix and various differentiated skeletal muscle fibers, while the cellular type is characterized by uniform populations of differentiating myoblasts .Three different types of extracardiac rhabdomyoma  can be distinguished by using light microscopy and immunohistochemical markers . DiffSince their benign biological behavior , the The peculiar aspect of our case report is represented by the successful conservative management of a rare tumor, which, to the best of our knowledge, has never been treated without a surgical approach. Also, the peculiarity of the case is represented by a rare diagnosis for a common children issue such as facial soft tissue swelling.Head and neck district surgery, especially in very young children, is associated with a high risk of complications. Surgery to remove a lesion in the masseter muscle could potentially result in injuries to the muscle itself, the parotid gland, as well as some branches of both the trigeminal and facial nerves. This can lead to disruptions in the development of chewing, swallowing, and speech functions during a crucial growth phase. It may also cause paralysis of the facial expression muscles and alterations in the sensitivity of certain areas of the tongue and the lower part of the face, as well as functional changes in the salivary glands. Equally important to consider is the potentially destructive scarring outcome, with both aesthetic and functional consequences.Our case report demonstrates the possibility to manage conservatively a rhabdomyoma of the cheek in the first years of life, when it is not associated with any other symptoms, provided a close clinical and radiological follow-up is feasible.Obviously, the “wait and watch” approach can always be reconsidered in case of clinical changes, such as a significant increase in size of the lesion and/or the onset of compressive symptoms; in those situations, surgery should be rediscussed. However, if the mass remains stable in size and clinically silent over time, excision surgery can be considered after the first developing years of infancy to limit interferences with crucial skills development of this period, such as solid food swallowing or vocalizations and phonation finalized to speech production.


Cardiac masses commonly involve primary tumors, metastatic diseases, and nonbacterial thrombotic and infective endocarditis. myxomas are the most common primary tumors, accounting for 75%. Hemolymphangiomas are a group of congenital vascular and lymphatic malformations that originate from the mesenchyme, with an incidence rate of 0.12%–0.28% per year. Hemolymphangiomas have been found in the rectum, small intestine, spleen, liver, chest wall, and mediastinum but have not yet been reported in the ventricular outflow tract in the heart. Herein, we report a case of a hemolymphangioma tumor in the right ventricular outflow tract (RVOT). The tumor was successfully resected, and the patient was followed up for 18 months and did not exhibit tumor recurrence. The incidence rate is 1.2–2.8/1,000 newborns, and there is no difference observed in the rate between the genders . However2.A 73-year-old female patient came to our outpatient clinic  for treatment owing to dyspnea after repeated physical activities, which she had experienced for >10 years and which got aggravated 8 days before her visit. Her vital signs were stable and were as follows: blood pressure = 123/65 mmHg, heart rate = 83 beats/min, respiratory rate = 22 breaths/min, body temperature = 36.2°C, and transcutaneous oxygen saturation = 95%. Patient characteristics included no heart murmur, a history of diabetes for 4 years, no previous history and family history of cancer, and no considerable weight loss.Initially, dyspnea was mild and it was relieved after resting. The patient did not undergo any treatment. However, 8 days before her visit, she developed dyspnea and therefore underwent transthoracic echocardiography (TTE) in a local hospital and was diagnosed with right ventricular obstruction. Subsequently, she was transferred to our hospital for treatment. No obvious abnormalities were observed in the results of the blood test, urinalysis, and tumor biomarker tests. The ultrasound did not detect any thrombus in the arteriovenous extremities. The electrocardiogram showed sinus rhythm. However, TTE detected a solid mural [a hypoechoic mass with a size of 35 mm × 30 mm in the anterior wall of the distal RVOT (under the pulmonary artery) with a wide base (of approximately 20 mm) and a slightly unclear boundary with a muscular layer] that occupied the distal RVOT. The mass caused mild stenosis of the RVOT. Magnetic resonance imaging (MRI) showed no cerebral infarction. Cardiac magnetic resonance imaging (CMRI) detected an abnormal signal from the round nodular parenchyma attached to the left anterolateral wall in the RVOT. The CMRI showed a slightly high signal on T1-weighted images, a high signal on T2-weighted images, a smooth outer edge approximately 29 mm × 23 mm × 30 mm in size, and RVOT stenosis . PulmonaAfter a multidisciplinary discussion, surgical treatment was recommended because the patient exhibited obvious symptoms of dyspnea, RVOT stenosis caused by a solid mural, and the possibility of coronary artery disease, and the risk of sudden death and the benign or malignant nature of the cardiac mass were unclear. With the patient's full informed consent, she was sent to the operating room for cardiac tumor resection and coronary artery bypass grafting under median sternotomy and cardiopulmonary bypass under general anesthesia. The left great saphenous vein was used as a bridge vessel during coronary artery bypass grafting. Transesophageal echocardiography (TEE) showed that the tumor's pedicle was located in the anterior wall of the RVOT; no regurgitation of aortic, mitral, and tricuspid valves; no abnormality in the atrial and ventricular septums; and no other cardiac anatomical malformations. Intraoperative heart enlargement was observed mainly in the right side of the heart, and a purplish red cystic tumor, with the size of approximately 30 mm × 30 mm, was observed in the RVOT, with complete envelope, no obvious adhesion to surrounding tissues . The carSubsequently, the patient was transferred to the intensive care unit (ICU) post surgery. The postoperative mechanical ventilation time was 6 h and the duration of stay in the ICU was 18 h. She recovered with an uneventful postoperative phase; the imaging reexamination showed no residual tumor and no valvular regurgitation. The electrocardiogram showed sinus rhythm, the conscious symptoms were relieved, and the patient recovered and was discharged on the 10th day post-surgery.The results of pathological tests showed that lacunae of different sizes were lined with a single layer of endothelium, similar to normal lymphatic vessels and some small blood vessels. The cavity was filled with fluid, which rich in proteins, lymphocytes, and erythrocytes. The results of immunohistochemical tests showed the tumor cell markers CD31+ and CD34+; therefore, the patient was pathologically diagnosed with hemangilymphangioma . After 13.Cardiac masses may be a primary cardiac tumor, metastatic tumor, atrial thrombus, or pericardial tumor. The incidence rate of primary cardiac tumor is 0.0138%–0.03% per year; 80% of the tumors are benign cardiac tumors and 20% are malignant tumors . Benign Generally, for intrathoracic tumors, we first recommend a biopsy to evaluate the benign or malignant nature of the tumor, and thereafter further evaluate whether surgery or adjuvant radiotherapy, chemotherapy , 16. HowCardiac tumours of mesenchymal origin are commonly known as haemangioma, lymphangioma. There are difficult to distinguish from them in terms of tumour appearance and imaging. Therefore, clinical diagnosis requires pathological examination after removal of the tumour. On histological examination, hemangioma is found to be vascular tissue and may form thrombi, lymphangioma is found to be vascular and lymphatic vessels –20. LympThe clinical symptoms of hemolymphangioma are nonspecific and determined by the location, size, and relationship between the tumor and its adjacent tissues . UsuallyA large mass resulted in stenosis of the RVOT and therefore a risk of sudden death, and the patient had developed a local pulmonary embolism, for which surgical treatment was an inevitable option. Because hemolymphangioma cannot be accurately diagnosed using imaging techniques, it is difficult to obtain an accurate diagnosis before surgery. Therefore, a definite diagnosis is possible only by postoperative pathological examinations.In this case, the head, chest, and heart of the patient were scanned using MRI and computed tomography to evaluate the presence of any tumor in the patient's head, heart, and the surrounding tissues to rule out the occurrence of peripheral lymph node metastasis. After the MRI examination, it was clear before surgery that the patient did not have cerebral infarction, thoracic lymph node enlargement. The right ventricle occupied the space and was completely wrapped, the boundary between the right ventricle and the surrounding area was clear, and no tumor was found to invade the myocardium.Hemolymphangioma can be treated by surgical excision of the tumor. In recent years, methods such as sclerotherapy, laser, electrocautery, freezing, have also been adopted to treat hemolymphangioma , 7, 24. Median thoracotomy is usually adopted for cardiac tumor resection. With the advancement in technology, new techniques such as right thoracotomy, thoracoscopic small incision, and cardiac mass resection by the Da Vinci robot system have also been adopted , 26. OwiPostoperative pathological examinations showed vascular and lymphatic tissues, and immunohistochemical tests indicated positive CD31 and CD34. The specific expression of CD31 and CD34 in vascular and lymphatic endothelial cells confirmed the diagnosis of hemolymphangioma , 27. TheIn conclusion, primary hemolymphangioma in the right ventricle is rare and difficult to be diagnosed by using preoperative laboratory tests and imaging examinations and requires surgical resection and a long-term follow-up. In addition, pathological and immunohistochemical tests are the only diagnostic tools for primary hemolymphangioma in the RVOT.


The skull base provides a platform for supporting the brain while serving as a conduit for major neurovascular structures. In addition to malignant lesions originating in the skull base, there are many benign entities and developmental variants that may simulate disease. Therefore, a basic understanding of the relevant embryology is essential. Lesions centered in the skull base can extend to the adjacent intracranial and extracranial compartments; conversely, the skull base can be secondarily involved by primary extracranial and intracranial disease. CT and MRI are the mainstay imaging methods and are complementary in the evaluation of skull base lesions. Advances in cross-sectional imaging have been crucial in the management of patients with skull base pathology, as this represents a complex anatomical area that is hidden from direct clinical exam. Furthermore, the clinician must rely on imaging studies for therapy planning and to monitor treatment response. It is crucial to have a thorough understanding of skull base anatomy and its various pathologies, as well as to recognize the appearance of treatment-related changes. In this review, we aim to describe skull base tumors and tumor-like lesions in an anatomical compartmental approach and present imaging methods that aid in diagnosis, management, and follow-up. Skull base lesions pose a significant diagnostic challenge as patients frequently present with limited and nonspecific clinical signs and symptoms. Imaging is therefore critical in the detection and differential diagnosis and can characterize lesions according to the site of origin, growth pattern, and tissue characteristics. In particular, magnetic resonance imaging (MRI), with conventional and advanced sequences, is a robust tool that can accurately define the lesion extent, which is essential for selecting optimal treatment strategies, anticipating surgical complications, and delineating targets for radiation therapy ,2,3. BotThe skull base forms the floor of the cranial cavity and separates the brain from other facial and neck structures. It is subdivided into three regions: the anterior, middle, and posterior cranial fossae, comprising paired  and unpaired  bones. The petro-occipital fissure subdivides the middle cranial fossa into one central and two lateral compartments. The central skull base is separated from the anterior skull base by the posterior border of the lesser and greater sphenoid wings and planum sphenoidale. The dorsum sellae, posterior clinoid processes, and posterior petrous ridges comprise the separation between the central and posterior skull base ,2,3,4,5.Given the complex anatomy of the skull base and the small size of its neurovascular structures, it is crucial that imaging be performed using thin slices and provide multiplanar reconstructions. CT is the modality of choice for the delineation of fine bony detail, detection of matrix calcification, and identification of aggressive features, such as bone destruction and erosion. CT should be performed using a slice thickness of 0.5–1 mm with a bone algorithm reconstruction, including multiplanar reformats .,69.68,69Cholesterol granulomas are cystic tumors that contain granulation tissue, blood products, cholesterol crystals, and multinucleated giant cells covered by a fibrous pseudocapsule. These lesions can be found in any aerated portion of the temporal bone, including petrous apex, middle ear cavity, and mastoid, with the mastoid air cells being the most common location. The pathogenesis is controversial, but the most accepted hypothesis is the obstruction-vacuum theory characterized by eustachian tube dysfunction, resulting in a chronic ventilation outlet obstruction that leads to recurrent mucosal inflammation and hemorrhage. Hemoglobin extravasations and cholesterol crystals degraded by hemoglobin cause irritation and trigger macrophage activity, resulting in giant cells and granuloma formation.CT typically demonstrates an expansile, well-marginated, and rounded lesion with bone remodeling and cortical thinning . ExpandiChordomas are rare tumors that originate from embryonic remnants of the primitive notochord, which represents the earliest fetal axial skeleton extending from the Rathke’s pouch to the tip of the coccyx. They can occur anywhere from the clivus to the coccyx and are usually seen between the age of 30–50 years. Following sacrococcygeal involvement, the clival region is the second most common location, accounting for 30–35% of cases ,73. ChorCT shows a centrally located, well-circumscribed, and destructive lytic retroclival mass with osseous erosion and, sometimes, marginal sclerosis. Lesions frequently contain coarse calcifications that reflect a sequestra of normal bone, rather than dystrophic calcifications. On MRI, lesions appear lobulated with well-defined margins, often centered at the level of the spheno-occipital synchondrosis. On T1-weighted images, the tumor is predominantly hypointense with varying degrees of heterogeneous hyperintensity due to intratumoral calcifications, hemorrhage, and/or mucoid components ,72,73. OChondrosarcomas are rare malignant tumors that arise from endochondral cartilage remnants along the skull base synchondroses. They constitute only 2% of all chondrosarcomas .Chordomas and chondrosarcomas have a similar appearance on CT and MRI and can be difficult to distinguish. In general, chondrosarcomas arise at paramedian fissures along the skull base, whereas chordomas occur midline along the notochordal remnant. On CT, chondrosarcomas appear as well-defined lytic lesions with permeative destructive margins and chondroid matrix calcifications in about half of the cases. In contrast, calcifications in some chordomas represent fragments of destroyed bone, although the distinction may be difficult. On MRI, both tumors have low-to-intermediate signal intensity on T1WI and high signal intensity on T2WI. However, T2 hyperintensity tends to be more prominent in chondrosarcomas due to the presence of a chondroid matrix. Both tumors show variable moderate-to-intense heterogenous contrast enhancement ,76,77,78Solitary skull base plasmacytoma is a rare tumor characterized by the localized proliferation of neoplastic monoclonal plasma cells. Although tumors are histologically similar to the bone lesions found in multiple myeloma, the latter is a systemic disease. Plasmacytoma is divided into two distinct forms: extramedullary plasmacytoma and intramedullary solitary plasmacytoma of bone. The intramedullary form is more common and may occasionally be multiple .Skull base plasmacytomas most commonly arise from the clivus and sphenoclival region, followed by the nasopharynx, petrous apex, and orbital roof . AccuratEndolymphatic sac tumor is a rare, highly vascular, and locally aggressive papillary cystadenoma originating from the epithelium of the endolymphatic sac and duct along the posterior aspect of the petrous temporal bone. It is typically encountered in young patients, with an average age of 22 years at presentation, and is associated with symptoms such as hearing loss, tinnitus, dizziness and facial nerve palsy. Tumors can be found in up to 15% of individuals affected with VHL disease, with bilateral occurrence in approximately 30% of patients ,85,86. SGlomus jugulare and tympanicum, also known as paragangliomas, are tumors that develop from glomus bodies near Jacobson’s nerve (tympanic branch of CN IX) and Arnold’s nerve (auricular branch of CN X). They typically affect adults aged between 40 and 60 years and are more common in women ,88. PatiThe clinical presentation can vary depending on the degree of involvement of the jugular fossa and middle ear and can include symptoms such as pulsatile tinnitus, hearing loss, and CN palsies. Assessing the extent of bony erosion, an involvement of the middle ear cavity, and intracranial extension are critical for surgical planning. CT is the modality of choice to demonstrate the erosion of adjacent bony structures, including the jugular and caroticojugular spines. CT is also helpful to determine the degree of extension into the middle ear cavity and infratemporal fossa as well as the integrity of the ossicles and bony labyrinth ,90,91.These tumors are highly vascular and can be assessed by DSA and MRA, which show an intense tumor blush, feeding vessels primarily from the ascending pharyngeal artery, and early venous drainage due to intratumoral shunts. On MRI, a “salt and pepper” appearance can be seen on T1WI and T2WI, where the “salt” represents blood products from hemorrhage or slow flow and the “pepper” represents flow voids due to high vascularity. Intense enhancement is typical on both CT and MRI  88,91].,91.88,91Arrested pneumatization presents as a focal variation of the marrow pattern within the central skull base and is a benign finding does not require intervention. It is important to recognize this entity as it is common and can be mistaken for pathology within the sphenoid sinus. The development of the sphenoid sinus begins at the age of 2 years and typically reaches adult size by the age of 14 years ,93. DisrAsymmetric pneumatization of the petrous apex is a frequent normal anatomic variant that can be mistaken for pathology. The petrous apex normally contains bone marrow in 60% of patients, is pneumatized in 33%, and is sclerotic in 7%. However, in 5–10% of patients, pneumatization is asymmetric.Asymmetric fatty infiltration of the petrous apex can result in conspicuous asymmetric high signal on T1WI and T2WI, which can be misdiagnosed as a contrast-enhancing lesion or a cholesterol granuloma. Correlation with intrinsic T1 hyperintensity on pre-contrast T1WI, fat suppression, and lack of expansion, enhancement, or bone destruction can aid in differentiation ,94.Arachnoid granulations are small protrusions of arachnoid tissue that extend through the dura mater into a dural venous sinus, where they drain CSF from the subarachnoid space into the bloodstream. They consist of a core of loose connective tissues that form a trabeculated network with wide interstices and endothelium-lined channels ,96. AberAberrant posterior temporal arachnoid granulations may sometimes mimic an enlarged endolymphatic sac or endolymphatic sac tumor. However, their sharply demarcated lobulated contours and signal properties on MRI, which are similar to CSF on T1WI and T2WI, are essential for accurate diagnosis. In contrast, endolymphatic sac tumors show heterogeneous T1 and T2 signal with focal T1 hyperintensities due to hemorrhagic and proteinaceous components, and they also enhance heterogeneously on postcontrast images. Occasionally, adjacent brain tissue may herniate into giant arachnoid granulations, resulting in gliosis with areas of T2 and FLAIR hyperintensities . Mu. Mu97]. Meckel cave cephaloceles can be congenital or acquired and may herniate into the petrous apex. They are believed to be caused by either normal CSF pulsation or chronically increased intracranial pressure transmitted into the Meckel cave through a patent porus trigeminus  98,99].,99.98,99Sinonasal mucoceles develop due to the continuous accumulation of secretions in a paranasal sinus or nasal cavity with obstructed drainage. Mucoceles are associated with bony expansion and sinus wall remodeling, with the frontal sinuses being most commonly affected, followed by the ethmoid sinuses. Enlarging mucoceles may distort the local anatomy and exert mass on adjacent structures, typically affecting the orbit and extending intracranially in severe cases. Associated infection can lead to subdural empyema, meningitis, cerebral abscess, orbital subperiosteal abscess, and subcutaneous Pott’s puffy tumor ,101.On CT, the complete opacification of the affected sinus is typical, along with thin peripheral enhancement, bone resorption, and thinned sinonasal walls and septations. In some cases, areas of complete bone resorption may be present, leading to dehiscence and extension of the mucocele into adjacent tissues ,102. On Invasive fungal sinusitis is the most aggressive form of fungal sinusitis and a source of significant morbidity and mortality. It is seen mainly in immunocompromised patients such as those with diabetes mellitus, neutropenia, and advanced AIDS. Patients usually present with dramatic symptoms, including a rapid development of fever, nasal congestion, epistaxis, facial pain, and a loss of sensation in the malar tissues. The disease progresses rapidly and is associated with high mortality (50–80%), mainly due to vascular invasion and systemic dissemination. Extension into the nasopharynx, orbit, cavernous sinus, or intracranial compartment is frequent, resulting in the loss of vision, proptosis, and neurological deficits ,104.Imaging manifestations can range from subtle findings in the early phase to a very aggressive disease that may mimic a malignant tumor. CT may reveal mucosal thickening with variable opacification of the affected sinuses, a prominence of the nasal mucosa, and fat stranding in the retroantral region, orbit, masticator space, and pterygopalatine fossa. Bone destruction is usually present to varying degrees, but in some cases, the bone may appear intact. Notably, the absence of bone destruction does not exclude spread to surrounding soft tissues, as Aspergillus tends to invade blood vessels even through intact bone . On MRI,The petrous apex is susceptible to pathologic processes that affect the middle ear and mastoid air cells, such as inflammation, infection, and obstruction. These conditions may lead to the accumulation of fluid in the petrous apex, which can persist even after the inflammatory process and clinical symptoms have resolved. Trapped effusion is a common incidental finding on MRI, which can result in an asymmetric appearance of the petrous apex with variable T1 and T2 signal, depending on the protein content . Signal Petrous apicitis is a rare complication of otomastoiditis, which occurs when infection spreads from the middle ear to the petrous apex via pneumatized air cells. Progression of purulent exudate leads to the destruction of air cell epithelium and demineralization of bony trabeculae. The infection can then spread to the bone marrow, causing a localized skull base osteomyelitis. The involvement of adjacent structures such as the carotid canal can result in vasospasm or arteritis of the internal carotid artery. Additionally, an involvement of emissary veins can cause thrombophlebitis and sinus thrombosis, and the infection can extend intracranially, resulting in meningitis, encephalitis, and intracranial abscess. CT can show opacification of preexisting apical air cells with associated otomastoiditis, mild expansion of the petrous apex, and permeative osseous destruction. However, bone changes may be subtle or absent early in the infectious process despite severe symptoms. On contrast-enhanced CT, petrous apicitis may appear as a heterogeneous enhancing mass that mimics a neoplasm. MRI is complementary to CT in the diagnosis of petrous apicitis and determination of the disease extent  2,71]. ,71. 2,71Paget disease of the bone is a chronic non-inflammatory disease characterized by localized excessive bone remodeling that affects widespread, non-contiguous areas of the skeleton. It is the second most common bone disease after osteoporosis, occurring in approximately 3–4% of the population over the age of 50, with a slight male predominance ,107. AltPaget disease of the bone is diagnosed primarily by radiological examination, which shows three distinct stages: lytic, mixed, and sclerotic. In the early stages, lytic activity predominates, causing focal osteolytic lesions. As the disease progresses, sclerosis becomes the predominant feature, leading to the characteristic cotton wool appearance with mixed lytic and sclerotic areas, along with thickened trabeculae, bone expansion, cortical thickening, and osseous deformity  106,107107,108. Ecchordosis physaliphora is a rare retroclival notochordal remnant that is usually asymptomatic and found in approximately 2% of autopsies. It is most commonly located in the retroclival prepontine region, but can also be seen anywhere along the midline from the skull base to the sacrum . On highGiant intracranial aneurysms, defined as larger than 25 mm in diameter, appear as expansile lesions of the cavernous sinus. They usually arise from the cavernous or supraclinoid internal carotid artery and can cause significant skull base erosion, extending into the paranasal sinuses, parapharyngeal space, and infratemporal fossa. Their recognition is critical due to treatment implications and, most importantly, to avoid a catastrophic biopsy. The imaging appearance of giant aneurysms depends on whether they are non-thrombosed or partially or completely thrombosed. Patent areas of an aneurysm will typically present with a prominent signal void on MRI due to rapid blood flow. Signal intensity is heterogeneous in the thrombosed portions of an aneurysm, which reflects the presence of different stage blood products and sometimes calcifications. The presence of flow-related artifacts in the phase-encoding direction may be helpful in the diagnosis . A potenThe skull base is a complex and challenging anatomical region due to the presence of crucial neurovascular structures that enter and exit the cranial vault. Owing to its deep location, it is not amenable to direct clinical examination aside from surgical exploration. There are various benign and malignant entities as well as tumor mimics that may arise from the skull base and surrounding structures, which pose diagnostic and therapeutic challenges. Radiologic imaging is the cornerstone for detection, differential diagnosis, treatment planning, and follow-up of skull base tumors. CT and MRI are the primary imaging modalities and complement each other in narrowing the differential diagnosis and planning treatment. Given the diverse nature of tumors and mimics that affect the skull base, some of which share overlapping clinical and imaging manifestations, a thorough analysis of relevant neuroimaging features is important for accurate lesion characterization.


Unicornuate uterus is a congenital uterine malformation. Unicornuate uterus with rudimentary horn, ovarian endometriosis, and congenital renal agenesis are rare combinations that can be easily misdiagnosed due to the lack of typical clinical manifestations.A 19-year-old woman with pelvic pain was admitted to the hospital after a month. Physical examination was unremarkable. B-ultrasound and CT scan both indicated pelvic ectopic kidney. In addition, renal scintigraphy revealed normal perfusion and function of the right kidney, but the perfusion and function of the left kidney were not visible. A left pelvic ectopic kidney was diagnosed by preoperative images. A laparoscopic left pelvic ectopic nephrectomy was performed after adequate surgical preparation. However, the postoperative pathological diagnosis revealed a rudimentary uterine horn with ovarian endometriosis and congenital renal agenesis. Fortunately, she got recovered and was discharged from the hospital after 5 days following the operation. Moreover, she received regular follow-ups at the gynecology clinic. To date, no right adnexal or uterine abnormalities have been detected on ultrasound during the follow-up visits.Rudimentary uterine horn with ovarian endometriosis and congenital renal agenesis are rare and are easily Misdiagnosed due to the lack of typical clinical manifestations. A gynecological examination is recommended for patients who may have this disease. Unicornuate uterus with a rudimentary horn is a rare congenital uterine malformation, whose clinical manifestations, including abdominal pain and dysmenorrheal, are atypical , 2. MoreThis patient was a 19-year-old G0P0  woman. She was admitted to the hospital for pelvic pain after 1 month. No symptoms, such as frequent urination, urgent urination, painful urination, or hematuria, were noted.She had no specific history and denied any personal or family history associated with cancer. Physical examination revealed that no palpable masses and percussion pain were found in bilateral renal areas. Laboratory testing was unremarkable. An ultrasound scan showed no kidney in the left renal area. The pelvic cavity was detected as a heterogeneous structure (7.3 × 4.6 cm). The mass had a clear boundary and an irregular appearance, with punctate blood flow signals. A CT scan and enhancement showed that no renal was seen in the left renal area. A solid structure was seen in the left pelvis (3.35 × 3.7 cm). A lamellar, hypointense shadow is seen in the center, and the solid portion of the enhanced scan is clearly enhanced. A tortuous and thickened tubular structure was seen locally . The enhOur patient requested surgical treatment due to a non-functioning left kidney and pain. A laparoscopic left pelvic ectopic nephrectomy was performed after adequate surgical preparation. Intraoperatively, the uterus was visible in the middle. On the left side of the pelvis, a mass with apparent adhesion to surrounding tissues could be seen; despite consultation with a gynecologist, the ovary and fallopian tube were not identified. On the right side, the fallopian tube and ovary were observed to be normal. We diagnosed a unicornuate uterus combined with a left pelvic ectopic kidney intraoperatively by inviting a gynecologist for a consultation. After adequate separation of the mass, we removed them intact. Gross examination showed a grayish-white and grayish-brown mass with a size of approximately 6.5 × 4.5 × 3.5 cm. The cut surface was cystic, and dark red material was visible. Microscopy showed a scattered distribution of endometrial, ovarian, and fallopian tube components but no kidney components –C. The pFortunately, she recovered and was discharged from the hospital 5 days after surgery. Moreover, she received regular follow-ups at the gynecology clinic. To date, no right adnexal or uterine abnormalities have been detected on ultrasound during the follow-up visits , B.The patient was admitted to the hospital after one month for pelvic pain; relevant laboratory tests and examinations were completed, and clinical consideration was left pelvic ectopic kidney in the 6 hospital days; laparoscopic left pelvic ectopic nephrectomy was performed in 7 hospital days; definite histological examination confirming a rudimentary uterine horn with ovarian endometriosis and congenital renal agenesis was made in 12 hospital days. To date, no right adnexal or uterine abnormalities were detected by ultrasound at follow-up .The incidence of unicornuate uterus is 1 in 4,000. Generally, the female reproductive system develops mainly from the Müllerian ducts. Müllerian ducts form the fallopian tubes, uterus, cervix, and upper two-thirds of the vagina, which together form the female reproductive tract. However, if one side of the Müllerian duct develops normally and the opposite side is defective, a unicornuate uterus is formed. According to the classification system of the American Society of Reproductive Medicine (ASRM) in 1988, this case is a type IIb uterine malformation, a unicornuate uterus with a non-communicating rudimentary horn  in areas other than the endometrium. It may occur anywhere in the body, mainly in the pelvic organs, such as the ovaries , 9. The The pathogenesis of the present case was more likely explained by retrograde menstruation, in which menstrual debris containing viable endometrial cells refluxing through the fallopian tubes into the ovarium and pelvic cavity, leading to ovarian endometriosis and pelvic adhesion on the non-communicating rudimentary horn side of the patient .The clinical presentations of rudimentary uterine horn with ovarian endometriosis, including dysmenorrhea and non-menstrual pelvic pain, are largely non-specific. It might be difficult to establish a definitive diagnosis in the early stages because of the non-specific and underlying symptoms, which can easily lead to severe consequences due to incorrect treatment .Sonography of the unicornuate uterus does not provide a reliable diagnosis. Conventional 2-dimensional sonography is especially difficult to use for detecting the rudimentary horn because it cannot appreciate the small size and lateral deviation of an isolated unicornuate uterus. However, the use of 3-dimensional sonography improves diagnostic accuracy by obtaining reconstructed images that depict the deviation of the unicornuate uterus and the characteristic appearance of the endometrium. In addition, MRI allows accurate diagnosis of all subtypes of the unicornuate uterus due to its multiplanar imaging capabilities and excellent soft tissue resolution. Hysterosalpingography reveals an isolated unicornuate uterus with a small, fusiform uterine cavity. However, it is not recommended for routine application because of its invasive nature and inability to appreciate the non-communicating rudimentary horn .In the present case, the clinical presentations of pelvic pain were non-specific. In addition, preoperative imaging showed no kidney in the left renal area. In contrast, a suspected renal mass was presented in the left pelvic region, so the diagnosis was considered a left pelvic ectopic kidney. There are differences in imaging between the rudimentary uterine horn and pelvic ectopic kidney . HoweverThe standard treatment option for the rudimentary uterine horn is surgical resection of the rudimentary horn and fallopian tube. However, confirmation of the diagnosis by adequate preoperative examination and intraoperative laparoscopic exploration is essential , 16. In The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.S-fY, J-gC, TZ, and R-lF collected data and drafted the manuscript. R-lF provided figures and pathology results and drafted the manuscript. S-zZ and Z-yY reviewed the manuscript. C-xK edited the manuscript and critically revised the draft. All authors contributed to the article and approved the submitted version.


Bochdalek hernias (BHs) are rare, and the presentation, diagnosis, and management of them can be complex. We present a 70-year-old man presenting with left flank pain who underwent a successful laparoscopic repair of BH with mesh placement. One of the many achievements of anatomist Vincent Bochdalek was to describe a peculiar hernia that arose as an error of diaphragmatic development. It is known as the ‘Bochdalek hernia' (BH), this congenital diaphragmatic hernia is the protrusion of tissue through a defect in the lumbocostal triangle of the diaphragm, also known as the foramen of Bochdalek. This foramen is a result of the improper fusion of the septum transversum and the pleuroperitoneal folds during the development of the hernia in gestation .A 70-year-old man presented with increasing pain in the left flank on a background of a known BH. The hernia was discovered five years before and managed non-operatively as the patient lived rurally and had been asymptomatic. Contemporary imaging via computed tomography (CT) demonstrated that the hernia was now larger, and that there was a 15 mm defect in the posterior hemidiaphragm on the left side, with herniation of intra-abdominal fat, most likely from the retroperitoneum . The herGiven the patient was having ongoing back and left flank pain, likely due to strangulation of the herniated intra-abdominal fat, a laparoscopic diaphragmatic hernia repair of the foramen of Bochdalek was performed. Following the establishment of pneumoperitoneum and safe laparoscopic port placement, the short gastric vessels were divided to enter the lesser sac. The lateral and superior borders of the spleen were mobilised to improve the exposure of the diaphragm. The hernia was identified; the main findings were a small defect approximately 3 cm × 3 cm over the left dome of the diaphragm behind the left kidney, containing fat , which wThe incidence of BH in infants is approximately 1 in 4000 . In contAsymptomatic BH occurs in approximately 0.17% of the adult population . OtherwiThe diagnosis of BH is challenging due to its rarity and its non-specific presentation in adulthood .Diagnosis may be obtained from plain radiographs or CT. A chest X-ray may demonstrate gas and organs above the diaphragm, whereas a CT is accurate in identifying diaphragmatic defects and signs of ischaemia . The usuDue to its presentation, delayed and missed diagnosis are common and can result in lethal complications. Once discovered, patients should undergo surgical repair as soon as possible, as mortality and complications are as high as 32% in emergency surgery, whereas the mortality rate for elective surgery is less than 3%. This makes early diagnosis vital in reducing the morbidity and mortality of the disease .The main complications of BH are obstruction, strangulation, perforation, and other coexisting anomalies. It was noted that up to 18% of cases were complicated by life-threatening strangulation [In the literature, both transthoracic and transabdominal approaches to surgical repair have led to similar outcomes . LaparotGiven the potential complications, this study aims to educate surgeons about BH, especially since it is an uncommon diagnosis that can present non-specifically. Surgeons should consider a lower threshold for operating on these hernias in the elective setting to prevent the occurrence of avoidable complications.


Central Giant Cell Granuloma (CGCG) is a non-neoplastic benign lesion. It is primarily observed in the maxilla and mandible, with the mandible being the more reported site of the lesion. The lesion often manifests in the anterior regions of the mandible, extending occasionally across the midline. This case reports a rare presentation in the posterior portion of the mandible, in an edentulous area.A 33-year-old female with a history of extraction of teeth 36 and 37 six months ago presented with a main complaint of a mass in the oral cavity. The oral examination revealed an expansive multilocular mass (4 × 3 cm) located on the alveolar ridge in the left posterior portion of the mandible, extending around tooth 33 with an intact masseter muscle. The histopathological findings were consistent with CGCG. Consequently, the lesion was surgically removed with no clinical or radiological recurrence observed during the 4-month post-operative follow-up.While previous reports of CGCG in the posterior portion of the jaw showed destructive lesions that caused mandibular ramus destruction along with swollen masseter muscle, this case reports no involvement of the masseter muscle. Also, while some studies linked CGCG to tooth-bearing regions, our case suggests a possible traumatic link even after extraction.This case presents a rare CGCG occurrence in the posterior jaw, notably without masseter muscle involvement. It also indicates that CGCG can manifest in edentulous regions. •This case represents a rare presentation of CGCG in the posterior portion of the mandible.•This CGCG case reports no involvement of masseter muscle.•This case suggests that CGCG can manifest even in edentulous areas. Interestingly, it is less frequently seen in the mandible than in the maxilla. These lesions often manifest in the anterior regions of the jaws, extending occasionally across the midline. In rare instances, they may affect the posterior jaws, including the mandibular ramus and condyle . The antTreatments CGCG are: excision biopsies, curettage with safety margins, and partial or full resection of the affected bone; injecting corticosteroids into the affected region has been successful . The mos2A 33-year-old female patient complaining of mass in the oral cavity was referred by her general dentist to the oral and maxillofacial surgery department of National Hospital in Mesyaf, Hamah in March 2023. Her main complaint was a painless swelling lump in the left jaw that had grown rapidly and increased in size over the previous months. It was first noticed after extracting the teeth 36 and 37 six months ago, the teeth 34 and 35 were previously extracted without any following complications. The patient reported no severe infection has been in the extraction area or in tooth socket of the extracted teeth or even in the tooth 33. The patient reported no tingling sensation of the left lower lip or sensory disturbance of the left chin with disocclusion and difficulty speaking and chewing. The functional examination of mastication muscles revealed there is no harming, destruction or pain but light debility. The examination involved the masseter muscle - The closest muscle to lesion - which was intact. An intraoral examination revealed an expansive multilocular mass (4 × 3 cm) on the alveolar ridge in the left posterior portion of the mandible and it extended around the tooth 33 . The extThe panoramic radiograph revealed a huge corticated radiolucency with well-defined borders of the left mandibular body measuring approximately 3 × 4 cm with minimum displacement of the teeth 33 . It invoHistopathological department received fragments of fibrous mass measuring 4 × 3 cm; showing a soft white-gray tissue. Microscopic examination of serial sections revealed a neoplastic proliferation consisting of sheets of rounded to polygonal cells with collagenized zones and uniformly numerous multinucleated giant cells. There were no abnormal mitoses or malignant changes . These fConsequently, intraoral curettage including en-bloc resection was applied. Using intralesional steroids were excluded due to the acromegaly of the lesion, and the long period that intralesional steroids take to be effective in this case, in addition to the patient's continuous suffering if this treatment method applicated on long term. The lesion was removed en-bloc with a bony security margin of 1 cm to remove the peripheral margins of the lesion, extending into the alveolar bone to the lingual soft tissues. All the soft tissues involved in the lesion had to be removed, including tooth 33 . FollowiFace muscles functions were checked post-surgery. No facial nerves dysfunction was detected, the functional occlusion was treated without restrictions on movement or pain and mastication started returning back normal. No evidence of clinical and radiological recurrence was observed during post-operative follow-up for 4 months.3The case we presented is a type of cases that reports a mandibular CGCG in the posterior portion, with swelling and pain as the main clinical features. CGCG is defined as an uncommon benign lesion of jaws that occurs in maxilla or mandible. Its clinical presentation is variable, ranging from an asymptomatic slow growing behavior to an aggressive painful lesion. Therefore, it is classified as a nonaggressive or an aggressive lesion depending on its radiological, pathological and clinical features . The radPrevious studies demonstrated that many CGCG cases are located in the anterior portion of the jaw crossing the median line . NotablyAccording to the clinical and radiological examination, a differential diagnosis of fibrous dysplasia, aneurysmal bone cyst, non-osteogenic fibroma, osteosarcoma and brown tumor of hyperparathyroidism was made. Histologically, it is indistinguishable from other giant cell lesions of the bone like cherubis and aneurysmal bone cyst. Giant cell granuloma forms a lobulated mass of proliferative vascular forms a lobulated mass of proliferative vascular connective tissue packed with giant cells. These giant cells are seen lying in vascular stroma, these giant cells have a patchy distribution and signs of bleeding into the mass and deposits of hemosidrin are frequently seen .One review illustrated that most CGCG patients developed the lesion without any signs of trauma, which suggests the neoplastic background of CGCG . HoweverAlthough the complicated localization of the CGCG in the posterior portion of the jaw in our case might draw attention to treat it conservatively, conservative treatments have yet not confirmed its priority over surgical treatment, especially in aggressive CGCG cases . Accordi4This case highlights a rare presentation of CGCG in the posterior portion of the jaw without involvement of the masseter muscle. It also indicates that CGCG can manifest in edentulous areas.CGCGCentral Giant Cell GranulomaWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethical approval is not applicable. The case report is not containing any personal information. The ethical approval is obligatory for research that involve human or animal experiments, so there is no institution that waived ethical approval.No source of funding.MA, MH: Drafting the article.KK: Critical revision of the article.OH: Supervision.All authors provided final approval of the version to be submitted.DDS, OMFS.Orwa Haidar None.


Mesenteric cysts are uncommon intra-abdominal lesions that account for only one in every 100 000 adult hospitalizations. Their diagnosis is based on a comprehensive clinical examination as well as radiological modalities such as ultrasonography and computed tomography (CT) scans, and it is usually a clinical challenge because of non-specific symptoms. We present our first case of a 51-year-old man with a simple mesenteric cyst accompanying acute appendicitis diagnosed by CT scan of the abdomen and treated by exploratory laparotomy, complete enucleation of the cyst and appendectomy with a 10 month follow-up without complications or recurrence. This type of presentation has not been thoroughly investigated, with only two children reported during our literature review. Even if there is a high level of suspicion, a CT scan is required for confirmation. Mesenteric cyst is a rare cystic disease that affects one out of every 100 000–250 000 hospitalized patients . BenevieA 51-year-old black male patient presented to our outpatient clinic with a 2-year history of intermittent abdominal pain. The patient was in his regular state of health until 2 years ago, when he began suffering discomfort in the left lumbar region, which then spread to the right lumbar region and right iliac fossa; nonetheless, the pain in the left lumbar region remained persistent. The pain developed gradually, was piercing and did not spread to other portions of his body. Some days he gave it an 8/10 grade, and other times a 4/10. It had no alleviating elements; however, straining during defecation exacerbated it. The pain was accompanied by a lack of appetite, fatigue, headaches and overall body weakness. It was also connected to a painful protrusion that manifested when he lay down. He was treated in a peripheral facility until ~10 months ago, when he was referred to our clinic for further management as his illness worsened and an ultrasound revealed an intra-abdominal mass. On examination, there was no palpable abdominal mass, but the abdomen was painful in the left lumbar region and right iliac fossa, with the pain being most intense at McBurney’s point. There was no rebound tenderness found. Past medical history of inguinal hernia was repaired 6 years ago.Routine laboratory investigations were done with the following values: HB 14 g/dl, WBC 3.4 × 103 u/l, neutrophils 30.8%, lymphocytes 53%, monocytes 11.2%, eosinophiles 4.5%, and renal and liver function tests were normal. Electrolytes were normal, and erythrosedimentation was 9 mm/h. The abdomen-pelvic ultrasound showed a huge, well-defined, thin-walled cyst with internal debris abutting the anterior-inferior surface of the left kidney, measuring 10 × 7.3 cm. The Doppler interrogation was unremarkable. The caecal appendix was not mentioned, and the suspected diagnosis was a mesenteric cyst. A CT abdominopelvic scan showed a well-defined ovoid intrabdominal mass (9.6 × 8.6 × 8.2 cm) with barely perceptible walls in the left lumbar region . There were no solid-enhancing components or calcifications. It had a minimal compressive effect on the adjacent loops of bowel; also, appendiceal dilatation and wall thickening were noted  and 2, wExplorer laparotomy was done founding a descendent mesenteric colon cyst of about 10 cm in both diameter, which was fully enucleated conserving the left colic artery that was running over the anterior surface of the cyst , and durHistopathology reported a cyst measuring 11 × 9 × 8 cm, filled with 300 ml of dark brown fluid and lined on the wall by a simple epithelium without malignancy, concluding it as a simple mesenteric cyst. The appendix showed a dilated wall with a mild acute inflammatory infiltrate in the muscular layer and vascular congestion; there was the presence of an intestine fragment with lymphoid follicle proliferation and many lymphocytes in the mucosa, concluding it as an acute appendicitis.The patient was discharged on post-operative Day 5 and was followed up in outpatient consultation for 10 months without complications or recurrence.A mesenteric cyst is one of the most uncommon abdominal tumours, with only about 820 cases reported since 1507. The incidence ranges from one per 100 000 to 250 000 admissions , 7. MostAbdominal pain is documented as the most common symptom; rarely is an abdominal distention or a mass found on physical examination. About 10% of patients present with acute complications such as intestinal obstruction, volvulus, torsion, intra-cystic bleed and leakage of infective fluid . Our patMost authors 50–67%) reported that the most common location for mesenteric cysts is the mesentery of the small intestine; ~24–37% of cysts were discovered in the mesocolon, and <1% of the cases have been reported in the mesentery of the descending colon, sigmoid or rectum [0–67% repImaging diagnostics of the mesenteric cyst are based on abdominal ultrasound, CT and magnetic resonance imaging , 10. In Standard therapy for mesenteric cysts is total resection. This procedure could be performed laparoscopically or via laparotomy . RecurreDespite a rise in the publication of case reports, mesentery cysts are generally an uncommon and poorly studied disease. Particularly in adult patients, their association or presentation with acute appendicitis makes them even rarer, necessitating clinical expertise and radiological images for a conclusive diagnosis. This case report could be a good starting point for other type of research that help to understand better the association between different intrabdominal conditions.I acknowledge no financial support from any institutions or organizations.None declared.


Hemangioblastoma is a rare, benign, and morphologically distinctive tumor. In most cases, the tumor involves the central nervous system. Extraneural occurrences are rare, with just a few reports of hemangioblastoma situated outside of neural tissue, such as the retroperitoneum. We report a case of sporadic retroperitoneal hemangioblastoma in an 87-year-old male patient, diagnosed as an incidental finding in a CT scan performed because of kidney stone disease. The CT scan showed a mass in the retroperitoneum posterior to the inferior vena cava. The patient reported no remarkable symptoms. We describe our path to diagnosis, the possible differential diagnosis for retroperitoneal masses, and the histopathologic features of the tumor. There are <250 reported extra neuraxial hemangioblastomas and just 14 reported cases situated outside of the neural tissue. Our case is the eighth case report of a hemangioblastoma arising from the soft tissue of the retroperitoneum. Hemangioblastoma is a rare, benign, and highly vascular neoplasm of uncertain histogenesis, consisting of networks of small blood vessels interspersed with lipid-laden stromal cells . This tuAn 87-year-old male Caucasian patient with a history of cardiac co-morbidities, diabetes mellitus type 2, and chronic kidney disease stage 4 was referred to our hospital for clinical evaluation and a non-contrast abdominal–pelvic CT scan because of right side pain with a history of kidney stone disease, with recurrent ureteral stones. The CT scan showed a small distal ureteral stone on the right side without the need for surgical intervention. Incidentally, he had a retroperitoneal mass (4.4 × 4 × 4 cm) posterior to the inferior vena cava, with compression on the inferior vena cava and the right renal artery . Our radin toto, which showed a pseudo encapsulation and an uneven surface. The patient recovered without complications and was discharged home on Day 6 after surgery. A few weeks after the surgery, the kidney function improved slightly.Because of the compression on the right renal artery and the unclear diagnosis, we decided to perform surgery. The resection of the tumor was performed through an open transperitoneal approach with a midline incision. Intraoperatively, the mass was adherent to the inferior vena cava and the right renal artery, making the separation very difficult. Ultimately, we removed the tumor Our pathologists found a circumscribed tumor surrounded by a connective tissue capsule, consisting of numerous thin-walled vessels of small to medium diameter, lined by flat endothelial cells without significant atypia, and on the other hand, epithelioid cells between the epithelioid cells with round oval nuclei, bright chromatin, partly with nuclear pseudo-inclusions, and pale-eosinophilic cytoplasm, without recognizable cell borders. Some of these epithelioid cells show a vacuolated cytoplasm. No mitotic figures are seen, no necrosis. The endothelia of the blood vessels are stained by immunohistochemistry using CD31, CD34, and ERG staining, but no interstitial cells are stored between the vessels. Interstitial epithelioid cells showed diffuse S100- and focally inhibin-positive. There was no expression of D2-40, PAX8, AE1/AE3, CK8/18, RCC, or CD10. Ki67 proliferation index was ~1–2%.Hemangioblastomas are rare tumors that typically occur in the central nervous system, in 25% of the cases as part of von Hippel-Lindau disease . OccasioOn the other hand, primary retroperitoneal tumors represent a very heterogeneous group of neoplastic and non-neoplastic entities that originate in the retroperitoneal tissues without arising from the organs located there. We can distinguish here between solid and cystic tumors and between neoplastic and non-neoplastic tumors. The best examples therefore are lymphoid tumors, sarcomas, neurogenic tumors, mature teratomas, Mullerian cysts, pancreatic pseudocysts, etc. . They ofIf the diagnosis remains unclear, surgery should be the next step. The decision for laparoscopic or open surgery depends mainly on the location, the contact with the adjacent structures, and the surgeon’s experience. However, retroperitoneal masses are challenging to reach, so we prefer the open approach in our clinic.Ulex europaeus I, have demonstrated a very variable expression [In the histopathology, the characteristics of hemangioblastoma included circumscribed borders, often solid, lack of mitotic figures, fine vacuoles and intracytoplasmic lipids, alternation of cellular and paracellular areas, nuclei pleomorphism, and arborizing capillary-sized vessels . Immunohpression .Our work shows the wide range of possible differential diagnoses for retroperitoneal masses. A hemangioblastoma arising from the soft tissue of the retroperitoneum is very rare but should be considered in the differential diagnosis of unclear retroperitoneal masses. Due to the unspecific symptoms and imaging features, clinical and imaging diagnostics are not enough, but a pathohistological examination is always required in such cases.


All three types of vessels are negative for CD21/CD35 and CD68. Hemangioma and littoral cell angioma are two frequent vascular tumors in the spleen that should be considered differential diagnoses. Both lesions lack the microscopic features of SANT and have only a single type of vessel. The vessels in hemangioma are , while in littoral cell angioma they are . There are no specific clinical or radiologic findings for SANT. It is important to recognize these characteristic features and to differentiate them from other benign and malignant lesions, such as angiosarcoma. A thorough histopathologic examination and IHC are helpful in making the correct diagnosis.Sclerosing angiomatoid nodular transformation (SANT) is a benign vascular lesion of the spleen with uncertain etiology. It predominantly affects women between the ages of 30 and 60 years. Clinically, it is asymptomatic or can cause abdominal pain, but usually discovered incidentally on imaging, which can identify a mass but may not provide a definitive diagnosis. In uncertain vascular lesions, there is always a risk of spontaneous rupture of large vessels and the potential for spreading malignancy. Hence, the final diagnosis is rendered on microscopy after splenectomy. A middle-aged female came to the clinic complaining of abdominal pain. Radiology showed a solid splenic mass and the patient underwent splenectomy. Gross examination showed a 3 cm white firm mass with focal hemorrhage. Microscopy revealed multiple nodules of variable sizes surrounded by fibrosclerotic stroma. The nodules showed round to slit-like vascular spaces with numerous red blood cells. The internodular stroma consisted of dense fibrous tissue with scattered plump myofibroblasts and lymphoplasmacytic inflammatory cells. These distinctive features lead to the diagnosis of SANT. SANT possesses characteristic histologic features with distinctive immunohistochemistry (IHC). IHC reveals three different types of vessels within the nodules as follows: (1) small veins (CD34 Sclerosing angiomatoid nodular transformation (SANT) is a rare benign vascular lesion of the spleen. Its exact pathogenesis is still uncertain . CommonlA radiology workup can identify a mass lesion but cannot provide a definitive diagnosis. Ultrasonography reveals a hypoechoic mass while a CT scan reveals a heterogeneous, low-attenuation lesion in the spleen . OccasioConsequently, the current standardized approach for diagnosing this vascular condition relies on histopathologic examination after surgical removal. Open or laparoscopic splenectomy is currently the preferred treatment for SANT to avoid the risk of spontaneous vessel rupture and to rule out the suspicion of malignancy . AlthougIn this report, we present a rare case of asymptomatic SANT in the spleen of a middle-aged woman. The incidental splenic mass was successfully treated with laparoscopic splenectomy and confirmed through postoperative diagnosis. Additionally, we provide a literature review on SANT to enhance understanding of this condition when encountering a splenic tumor.A middle-aged woman with a medical history of diabetes mellitus underwent an abdominopelvic CT scan for an unrelated condition. The scan incidentally revealed a hypodense mass lesion in her spleen, measuring 1.7 cm in its largest dimension. Over a span of four years, the mass grew from 1.7 cm to 3.4 cm  infection, leading to some calling it an inflammatory pseudotumor. Additionally, there have been links made between SANT and immunoglobulin G4-related autoimmune diseases ,8. HowevInitially, it was suggested that SANT commonly occurs during middle age, with a predilection for females. However, as more cases have been reported and studied, this female preponderance may have decreased .Diagnosing SANT preoperatively remains a challenging task. Radiology workup can offer valuable clues that help narrow down potential differentials. CT scans often depict the lesion as a hypodense mass with a well-demarcated border and peripheral nodular enhancement, which suggests the presence of a vascular rim. MRI typically shows centripetal and progressive enhancement of the lesion.These radiological findings may provide indications that the lesion represents a non-malignant vascular type, such as hemangiomas. However, it is important to note that similar imaging characteristics can also be observed in malignant lesions, such as angiosarcoma. Therefore, despite the valuable insights from radiology, histologic examination remains the gold standard method for diagnosing such rare lesions .During the initial histopathologic examination conducted by Martel et al. and several other researchers, they identified three characteristic and distinct types of blood vessels within the lesion . The firThese three distinct types of small blood vessels closely resembled the normal composition of the red pulp in the spleen. Importantly, D2-40 staining was negative in the endothelial cell linings, providing further confirmation of the lesion's vascular origin instead of being of lymphatic origin.Identifying vascular lesions of the spleen, including SANT, can be challenging due to several other lesions with similar morphological and immunohistochemical characteristics. These lesions span a spectrum from benign to malignant. Among the benign lesions are littoral cell angioma, hemangioma, lymphangiomas, and hamartoma. On the other hand, the malignant category includes angiosarcoma.Littoral cell angioma is a benign vascular type of lesion of the spleen that arises from the littoral cells. These cells line the splenic sinuses and perform a role in hemophagocytosis . MicroscSplenic hemangioma, arising from sinusoidal endothelial cells is the most prevalent benign lesion found in the spleen . It can Lymphangioma is a benign tumor affecting the lymphatic endothelium in the spleen. It can manifest as either a single nodule or as a diffuse process. Most of the cases present cyst formation, but some cases show capillary and cavernous patterns. Histologic examination reveals cystic spaces lined by a single layer or multiple layers of endothelial cells. The cystic spaces are filled with pinkish proteinaceous material. Notably, apart from the conventional endothelial markers, the lymphatic endothelium exhibits strong immunoreactivity for D2-40 while being negative for CD21 and CD8 .Splenic hamartoma (SH), also known as splenoma, is a rare vasoformative lesion of the spleen arising from the cells lining the splenic sinuses. Under microscopic examination, it is characterized by predominantly disorganized red pulp elements with limited fibrous trabeculae. There may be varying amounts of extramedullary hematopoiesis as well. Unlike in some other lesions, splenic hamartoma typically lacks lymphoid follicles and dendritic cells. IHC reveals positive expression for factor VIII, CD31, CD8, and type IV collagen, while CD21 and CD68 show negative results. Distinguishing features between SH and SANT include the absence of a nodular growth pattern in SH and the presence of the classical immunophenotype in SANT .Angiosarcoma stands as the most prevalent non-lymphoid malignant primary tumor affecting the spleen . HistoloIn terms of management and prognosis, SANT behaves in a clinically benign manner and has a favorable prognosis. To date, no recurrences have been reported. The gold standard treatment is splenectomy. However, during the surgical procedure, caution is exercised to avoid morcellation of the spleen. This approach is taken due to the uncertain nature of the lesion's diagnosis and to prevent the seeding of potential malignancy. Lastly, it is significant to provide proper vaccination after splenectomy to prevent infection, especially against encapsulated bacteria.To the best of our knowledge, there are approximately 170 cases described in the literature. As of now, there are no specified clinical-radiologic findings. It is far more significant for the pathologist to recognize this rare lesion. The distinct morphologic features, along with IHC differentiate it from other non-malignant or malignant lesions.


Duplication of the transverse colon is a rare gastrointestinal malformation. Its pathogenesis is still unclear, and it is extremely rare in adults. Patients often present with symptoms of tumor compression such as abdominal mass, abdominal pain, and constipation as the first manifestation.A patient with a duplication of the transverse colon was admitted to the Department of General Surgery of our hospital. Laparoscopic exploration found a mass at the rear of the transverse colon near the splenic flexure, and the root was connected to the middle portion of the transverse colon.Surgery is a radical treatment and reduces the possibility of perforation, bleeding, obstruction, and cancer. Intestinal duplication malformation is a rare congenital gastrointestinal malformation clinically known as ileal and ileocecal valve malformations. The condition is more common in children under the age of two, with the most common type being ileal and ileocecal valve malformations (approximately 60%), followed by the jejunum (8%), colon (6%) and rectum (5%). Intestinal repeats can generally be divided into four structures 1): tubular structure attached to the mesenteric side separated from the normal intestine 2); double-tube structure communicating with the intestinal lumen (3); cystic structure attached to the mesentery and not communicating with the intestinal lumen; and (4) spherical structure adjacent to the intestine Figure 1: tubular; double-On January 2, 2023, an unmarried 30-year-old male patient presented with intercropping epigastric distension and pain that had persisted for over a month and worsened over the past week. One month prior, the patient experienced epigastric tenderness without being predisposed to referred pain, nausea, vomiting, acid belching, or hiccups. 2023 January 26 to another hospital to check the abdominal computed tomography (CT) suggests: “The left middle abdominal soft tissue mass is occupied, considering the malignant tumor lesion, there is pipeline communication between the lesion and the transverse colon, and the gas accumulation is seen in it, the other end is the blind end, and the periphery of the lesion exudes, and multiple enlarged lymph nodes can be seen”. After rehydration, pain relief were administered. However, there was no significant improvement, and the patient was transferred to our hospital to enroll in the “abdominal pain” department. Upon admission, the patient complained of obvious swelling pain and occasional colic with cold sweats, but there was no cough or eating obstruction. The patient reported poor sleep, normal urine adjustment, and 2-3 bowel movements per day, with no black or bloody stool. There was no previous family history of intestinal congenital diseases. There was no previous history of abdominal surgery. Physical examination revealed a flat abdomen with no gastrointestinal type, peristaltic waves, mid-upper abdominal tenderness, rebound tenderness, and no palpable mass. After a complete 3.0 T full abdominal magnetic resonance (MRI) plain scan and enhancement, the patient was diagnosed with a soft tissue mass in the left middle abdominal tube with a size of approximately 6.4*4.7 cm. The mass showed a long T1 and long T2 signal, and multiple gas signals were seen inside the lesion. The sac-like long T1 long T2 signal shadow was seen behind the left peritoneum, the size was approximately 2.1*1.3 cm, and the enhanced scan did not show strengthening. The results suggest the presence of left mid-quadrant lesions, which could be inflammatory lesions or lymphoma that need to be drained. Moreover, there was a left retroperitoneal cystic mass, which could be a benign lesion, but lymphangioma was possible, and regular review was recommended. In the case of barium enema colitis, the upper right edge of the transverse colon is seen to the right to left, with a walking curved thin bowel tube-like shadow. The base is approximately 42 mm wider, and in the supine position, it is inflated, the prone position is full, the liquid level is visible in the distal section of the vertical position, the total length is approximately 190 mm, the blind end is seen, and a titanium clip can be seen in the proximal section. The results suggest an abnormal open bowel lesion in the transverse colon. A painless colonoscopy revealed a dilated lumen and an open-like structure in the reverse scope. Pathological diagnosis showed chronic inflammation of mucosal tissue covered with squamous epithelium and gastric columnar epithelium  AND/OR minor(s)’ legal guardian/next of kin] for the publication of any potentially identifiable images or data included in this article.XZ and GD conceptualized the report. GG supervised the data collection. XZ and GD drafted the report. All authors contributed to the article and approved the submitted version.


Heterotopic gastric mucosa (HGM) can be found anywhere in the gastrointestinal tract but is most commonly located in the proximal esophagus . It can We describe a boy presenting in our institution at the age of 10-year old. He had history of gastroesophageal reflux disease (GERD) in the first year of life, treated with a proton pump inhibitor (PPI) and alpha-1 antitrypsin deficiency (AATD) (genotype Pi*ZZ), with cholestatic hepatitis treated with ursodeoxycholic acid. At the age of 6, he had two episodes of self-limited food impaction. An EGD was performed on the suspicion of eosinophilic esophagitis (EoE) but showed grade C esophagitis of middle third of the esophagus and EoE was histologically excluded. Treatment with PPI was initiated. On re-evaluation, 4 weeks after PPI suspension, he maintained esophagitis (grade B). PPI was continued on an on-and-off approach and two more EGDs were performed, showing esophagitis with superficial erosion of the esophageal mucosa. Normal range gastrin and pepsinogen I and II excluded gastric hypersecretion, and a normal esophageal transit exam confirmed the absence of hiatus hernia. Nevertheless, he was proposed for a Nissen fundoplication. By this time, he approached our institution. Another EGD was performed, revealing a pink inlet vertical patch of the middle and distal esophagus Figs. , with a Epidemiologic data concerning HGM is scarce, with a suspected prevalence ranging from 0.1% to 10% regarding endoscopic detection . A pediaThis case presents with unusual HGM location and the differential diagnosis with esophagitis was challenging. In most cases, HGM is found accidentally, an often without symptoms. Our patient had a symptomatic presentation, food impaction, but was extensively studied before a definitive diagnosis was established.We did not find any other case reporting the association of AATD and esophageal HGM in the literature, so we can only assume that this was an incidental finding of the two pathologies in the same patient. However, since both are underdiagnosed pathologies, the association may be underrecognized ,2,6.The clinical diversity of HGM ranges from asymptomatic to severe consequences such as strictures, ulceration, bleeding, perforation, fistulae, and even concern about malignant progression to esophagus adenocarcinoma, although this is a rare, sporadic event ,2. SinceAccording to the von Rahden et al classification , the patThere are no established clinical guidelines regarding the follow up of esophageal HGM . ClinicaIn conclusion, HGM is an underdiagnosis condition, easily missed in routine EGD and, as showcased here, easily misdiagnosed as a more common disease. Depending on classification, conservative treatment may be advised but close monitoring is essential to expeditious intervention in case of complications.The parents are aware of this Case Report and have they given their consent.


Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare compression syndrome that poses a challenge to many clinicians due to its ambiguous symptoms. It is predominantly common in females in their 30s to 50s.A 74-year-old male presented with generalized chronic postprandial abdominal pain, anorexia, and weight loss of 6 kg for the past 2 months. Physical examination, abdominal ultrasound, endoscopy, and colonoscopy were all unremarkable. His laboratory workup and tumor marker tests were within normal ranges. Finally, a multi-slice computed tomography (MSCT), an advanced computed tomography with multiple detectors resulting in faster and higher resolution imaging, outlined external compression on the celiac artery (CA) by the median arcuate ligament (MAL). The release of the CA from the MAL was done laparoscopically. Symptoms improved significantly postoperatively. During the follow-up period of 3 years, the patient did not regain his lost weight but had no other complaints.Due to its vague manifestations, MALS is diagnosed only after extensive evaluation and exclusion. This challenging diagnosis outlines the need for refined diagnostic guidelines. An MSCT plays a crucial role in confirming the diagnosis. Currently, more physicians prefer laparoscopic release of the MAL compared to an open approach.Despite MALS predominance in females, the diagnosis of MALS should be considered in males with postprandial abdominal pain and unexplained weight loss. An MSCT, along with other imaging modalities, can provide a comprehensive view of celiac compression. Laparoscopic decompression of the CA is an ideal treatment option. HighlightsMedian arcuate ligament syndrome (MALS) is an uncommon syndrome that typically presents with postprandial epigastric pain and unexplained weight loss.MALS is a challenging diagnosis of exclusion, and further studies are needed to reform diagnostic guidelines to provide patient relief as early as possible. A multi-slice computed tomography (MSCT) plays an important role in confirming the diagnosis.Clinicians need to keep in mind MALS in patients with postprandial epigastric pain, unintentional weight loss, and loss of appetite, despite an unclassical demographic.Compared to an open approach, laparoscopic decompression of the celiac artery is advantageous, especially in centers with experience.1. In rare cases, the ligament can lead to significant compression of the celiac artery (CA). Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery compression syndrome, is a rare vascular compression syndrome that poses a challenge to many clinicians due to its nonspecific symptoms, including exercise-induced or postprandial abdominal pain, nausea, vomiting, and weight loss, and lack of consensus on a diagnostic criterion1. The etiology behind these symptoms is not fully understood, and management revolves around a multitude of methods that includes MAL release with or without celiac gangliectomy and angioplasty through open laparotomy, retroperitoneal endoscopy, laparoscopy, or robot-assisted surgery1. We present a case of a 74-year-old male with MALS that caused abdominal pain and weight loss. This case report has been reported in line with the SCARE  Criteria2.The median arcuate ligament (MAL) is a continuation of the posterior diaphragm that wraps over the aorta and passes superior to the origin of the celiac arteryA Syrian male in his 70s presented to the gastroenterology department with chronic epigastric pain and loss of appetite as his main complaints. His generalized abdominal pain was worse with food ingestion, not associated with the position, and persistent for the past 2 months despite antacid use. He unintentionally lost 6 kg of weight since the onset of his symptoms but reported no nausea, vomiting, bloating, or change in defecation habits. He endured a significant loss of appetite a few weeks before his presentation. His medical and drug histories were unremarkable, aside from over-the-counter medications. He denied smoking or drinking alcohol.Physical examination was unremarkable. His vital signs included a body temperature of 37°C, 95% oxygen saturation, 110/70 mmHg arterial blood pressure, and a heart rate of 70 beats per minute. His initial laboratory workup, including a complete blood count with differential kidney functions, liver functions, thyroid function tests, electrolytes, and serum and urinary amylase, was within normal range. Tumor markers CA (carbohydrate antigen) 19-9, CEA (carcinoembryonic antigen), and PSA (prostate-specific antigen) were 8.43, 1.06, and 6.6 µg/l, respectively.An abdominal ultrasound revealed no abnormal findings. The patient was then referred for an upper gastrointestinal endoscopy which uncovered an uncomplicated small hiatal hernia with linear hypertrophic gastropathy in the body and antrum of the stomach. A biopsy of the duodenum revealed chronic duodenitis without villous atrophy (Marsh score 0). Additionally, a lower colonoscopy incidentally found internal hemorrhoids (grade I) with papilloma through retroflexion of the scope.Despite extensive investigations into the cause of his abdominal pain, no underlying etiology could be recognized. The decision was made to perform a multi-slice computed tomography (MSCT) with contrast. The MSCT revealed mild narrowing near the origin of the CA along with a thickened MAL (>7 mm) Fig. A. These A laparoscopic surgical procedure was scheduled to relieve extrinsic pressure from the CA by cutting the MAL. The surgery was conducted by a senior surgeon, and five laparoscopic ports were used Fig.  after geAnother MSCT was conducted after the procedure. It confirmed the successful release of extrinsic pressure over the patent CA Fig. B. The pa3. Only one case has been described within Syria4. With an incidence of 2 per 100 0005, MALS is most common in 30–50-year-old females (4:1 ratio) with thin stature6. Many cases of MAL compression are found incidentally in the general population, and the majority remain asymptomatic. In a review of 400 asymptomatic patients, 7.3% demonstrated significant  celiac axis stenosis7. In symptomatic patients, symptoms typically include postprandial abdominal pain and unexplained weight loss. Other vague symptoms, such as nausea, vomiting, and diarrhea, can occur8. Moreover, a physical examination may reveal nonspecific abdominal tenderness and bruits, exaggerated on expiration6.MALS, which is also known as Dunbar or celiac axis/artery compression syndrome, is an uncommon disorder characterized by compression of the celiac trunk by the MAL, leading to decreased blood demand and eventually foregut ischemia. The disorder was first described by Harjola in 19689. However, it is dependent on the operator’s experience. Furthermore, the patient body habitus and overlying bowel gas can limit its accuracy. Additional modalities, such as computed tomography angiography and magnetic resonance angiography, can be used to visualize CA compression in a three-dimensional view and confirm MALS8.Because of its imitation of many abdominal disorders, MALS is usually a challenging diagnosis of exclusion. As a result, patients undergo extensive assessment with many inconclusive tests before arriving at a diagnosis. Duplex ultrasound is a common initial screening tool. Its preference relies on being noninvasive, inexpensive, and helpful in detecting at least 50% and at least 70% celiac artery stenosis through peak systolic velocity10. However, the rate of conversion to open surgery is relatively high (9.1%) and may be attributed to the learning curve associated with this technique11. Intraoperative ultrasonography is usually advised to assess CA flow after decompression. However, its use might be unnecessary because of reports outlining the resolution of symptoms both with and without ultrasonography13. Moreover, postoperative percutaneous transluminal angioplasty (PTA) may be used in combination with laparoscopy and has shown good outcomes in patients with recurrent artery stenosis after MAL decompression6.The primary objective of MALS treatment is to relieve the overlying pressure from the celiac axis. The conventional method of treatment is through an open laparotomy that includes decompression alone, decompression with celiac dilatation, or decompression with reconstruction. Laparoscopic MAL release is becoming the modern standard for treating MALS due to its several advantages In our case, the patient was a 74-year-old male, which is outside the classical demographic of younger women with thin body habitus. The patient’s old age and presenting symptoms of chronic postprandial pain, weight loss, and anorexia prompted the search for gastrointestinal (GI) tumors and other causes of obstruction. Peptic ulcer disease, celiac disease, inflammatory bowel diseases, and mesenteric ischemia were also suspected. After indeterminate, normal ultrasound findings and laboratory workup, upper endoscopy and colonoscopy excluded diseases, tumors, or obstruction of the GI tract. A duplex ultrasound could not be obtained due to the lack of an experienced practitioner at the time. An MSCT with contrast confirmed the diagnosis of MALS and excluded atherosclerosis. Laparoscopy was the preferred approach to decompress the CA in our patient. Intraoperative ultrasonography and PTA were not used during the procedure. Symptom relief occurred immediately after surgery. During the 3-year follow-up period, the patient continued to have no symptoms but did not regain his lost weight.We present a case of MALS in an unclassical demographic of a 74-year-old male. After an indeterminate extensive evaluation, MALS was diagnosed with an MSCT, and laparoscopy was performed accordingly. The patient did not regain his lost weight but had significant symptom relief postoperatively. This case outlines the importance of keeping MALS as a differential diagnosis in cases of vague gastrointestinal symptoms and the need for better diagnostic guidelines due to the challenging presentation of this syndrome.Given the nature of the article, a case report, no ethical approval was required.Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.None.Z.A.H., G.A., A.H., and G.H.: writing – original draft, review, and editing; C.A.: supervision, final review and editing, and patient’s gastroenterology care and follow-up; S.K.: supervision, review and editing, and patient’s surgical care; R.J.: supervision, review, and editing, and performed patient’s imaging. All authors read and approved the final manuscript.The authors declare that they have no conflicts of interest.None.Not commissioned, externally peer-reviewed.None.Chaza Alsayed, MD.


A tracheal diverticulum (TD) is a generally benign medical condition, where there is an outpouching of the tracheal wall. Additionally, it is generally asymptomatic but there have been reported cases of adverse outcomes linked to TD. Here we present a case of a tracheal diverticulum that was incidentally found during the workup for stroke in a patient. Moreover, due to its radiologic appearance, there was concern for pneumomediastinum. We highlight the presentation and clinical importance of TD owing to the complications one is predisposed to from having this condition. A tracheal diverticulum (TD) is considered an uncommonly diagnosed medical condition in which there can be an outpouching of the tracheal wall with a currently reported prevalence of 2.4-8.1% -7. This We present a case of an incidental finding of TD during a stroke/transient ischemic attack (TIA) evaluation in the emergency department in hopes of highlighting awareness of TD given that chest imaging is now ubiquitous in clinical practice and the importance of documentation of this condition for managing patients given reported associated adverse complications.This is a case of a 59-year-old female with a known past medical history of asthma, schizophrenia, and Parkinson's disease, who was brought into the hospital with the chief concern of lightheadedness. She presented with associated nausea, left-sided headache, and worsening body stiffness with an inability to ambulate for five days. Upon presenting to the emergency department, the patient was worked up for a stroke. Computed tomography (CT) of the head, CT angio of the head and neck, and CT perfusion were performed, which ruled out an acute cerebrovascular accident; however, on the CT angiogram of the head and neck, she was found to have an incidental finding of pneumomediastinum in the right superior thoracic cavity without extension into the neck. She denied having a history of shortness of breath, coughing spells, nausea, or vomiting associated with retching and denied any substance use. Pulmonary services were consulted and a dedicated CT chest was performed, which suggested the air pocket was likely a congenital TD Figures , 2 and rTD, a type of paratracheal air cyst, is characterized as a benign out-pouching of the tracheal wall lined by ciliated columnar epithelium ,8. TypicAlthough rare, TD can be symptomatic, manifesting as recurrent respiratory tract infections since the cavitation becomes a nidus for infections. Chronic cough, hemoptysis, dyspnea, stridor, and dysphonia are among the other symptoms that are associated with TD . The preCurrent literature also revealed that TD predisposes patients to significant complications and/or may be associated with worse outcomes. Potential complications include infections that may even progress to paratracheal abscesses or empyema secondary to recurrent upper respiratory tract infections ,16. The Often incidental and asymptomatic, TD can be misdiagnosed as pneumomediastinum in imaging studies. In the rare instance a TD is symptomatic, it may present as recurrent respiratory tract infections or chronic cough, therefore warranting further evaluation and treatment. If the patient is asymptomatic, treatment is not indicated. However, despite its benign course, it is recommended to include TD as a differential diagnosis in the evaluation of imaging given its complications.