Gastro-Intestinal stromal tumours (GISTs) are rare and our understanding of their natural history and optimal treatment are continually evolving. Port site metastasis after laparoscopy for a GIST is an extremely rare phenomenon.We report a case with relevant imaging and discuss factors that may have contributed to the development of this isolated metastasis.Percutaneous methods of sampling GIST tumours for analysis should be avoided if at all possible. When necessary, prophylactic measures should be utilised to minimise the risk of seeding. Gastro-Intestinal stromal tumors (GISTs) are rare, and our understanding of their natural history and optimal treatment are continually evolving. This case report of a port site metastasis following laparoscopy for a malignant GIST is, to our knowledge, only the second documented case. As well as an outline of the case itself, the question as to why these arise and what the optimal treatment should be is also discussed.A 75 year old female presents to her General Practitioner with symptoms of lethargy, weight loss and occasional vomiting. Abdominal examination reveals a large mass in the epigastrium and blood investigations reveal a microcytic anaemia with a Haemoglobin of 9.4 g/dL. Her only past medical history includes atrial fibrillation and a total abdominal hysterectomy and bilateral salpingo-oophorectomy for benign disease.She is urgently referred for further investigation. Computed Tomography (CT) scanning demonstrates a 13 cm multi-loculated mass adjacent to the anterior wall of the stomach radiologically suspicious for a Gastro-intestinal stromal tumour (GIST). A subsequent PET-CT scan also demonstrated multiple peritoneal seedlings , the large mass anterior to the stomach was biopsied as were the peritoneal seedlings. Histology demonstrated a malignant GIST, strongly positive for CD117. She was discussed at the regional Upper GI Multi-Disciplinary meeting, and the decision made to commence systemic oncological therapy with Glivec (Imatinib).Encouragingly, her response to treatment was excellent and within one month a demonstrable radiological improvement was noted Figure . At ten Unfortunately, although she remains clinically asymptomatic, a follow up PET-CT  demonstrated a small discrete focus of uptake within the internal oblique muscle on the right side Figure . This coIn light of the confirmation of a port site metastasis (PSM), she is due to be discussed again in the MDT meeting prior to making a final decision regarding further treatment. The evidence base for the treatment of port site recurrences originating from common tumours is limited. In the context of this particular case i.e. a GI Stromal tumour, it is non-existent.Gastro-intestinal stromal tumours are the most common mesenchymal tumour affecting the GI tract. They may present in a variety of ways, can range from small to very large and demonstrate a great diversity in their malignant potential. Tumours are often positive for the c-KIT CD117) protein which is a tyrosine kinase receptor and is the most sensitive and specific marker. Mutations of this CD117 proto-oncogene are associated with stromal tumours and hence the use of long term Imatinib (a CD117 inhibitor) in their treatment [17 proteiIn many ways, the presentation in this case with a malignant GIST is fairly typical. Bleeding, and resultant anaemia, is often the precipitating event leading up to presentation. Malignant tumours often have a palpable mass at diagnosis and response to Glivec  can be dramatic.Generally speaking, pre-operative biopsy is not advised in patients who are radiologically diagnosed with a GIST and resectable. However, in the event of more widespread disease, where histological confirmation is required to commence oncological treatment, endoscopic biopsy techniques are preferred in order to limit the possibility of peritoneal contamination. Failing this, percutaneous techniques  remain the only alternative, both presenting a theoretical risk of tumour seeding ,3.Port Site metastases (PSM) although rare, have been extensively documented for other gynaecological and GI malignancies. When they occur, they often do so in the presence of advanced disease, and it is not uncommon for them to occur in isolation ,5. TheirMechanisms thought to be involved in the development of PSMs include high pressure CO2 insufflation, the degree of tumour manipulation during surgery, direct seeding during unprotected tumour/instrument withdrawal as well as the biological characteristics of the cancer itself ,7.In this particular case, laparoscopy (and hence gas insufflation) was required because of failure of alternative techniques to establish the diagnosis. The tumour was biopsied and the biopsy instrument removed through the port , although the port itself then required removal. The advanced nature of the tumour also increased the risk of a PSM but as far as we know, the port did not enter the peritoneal cavity at the site of an existing peritoneal metastasis.As far as the authors are aware, there is only one previously documented case of port site metastasis (PSM) following laparoscopy for a stromal tumour . AlthougIn this particular case, further treatment options could include surgical resection of the port site or the use of a second line agent such as sunitinib. This latter decision would be made on the assumption that the development of a port site metastasis whilst on first line treatment, confers the development of tumour resistance to this intial therapy. This is a phenomenon that has been increasingly well documented in the literature , and sucPercutaneous methods of obtaining histological evidence of GIST tumours, should be avoided if at all possible. When necessary, the reporting of PSM's suggests that prophylactic measures should be utilised to minimise the risk of seeding.The authors declare that they have no competing interestsAD performed the literature search, wrote and submitted the manuscriptWA assisted with the literature search and obtained the images presented from the Nuclear medicine Dept.SP performed the surgery, was the consultant in charge of the patients' care and made alterations to the final draft of the paper.All authors read and approved final manuscriptWritten consent was obtained from the patient for publication of this case report


Orbital infiltration in patients with multiple myeloma is a rare condition, with less than 50 cases reported in the medical literature. Most patients undergo conservative treatment because multiple myeloma is a disseminated systemic disease.A 43-year-old male subject with multiple myeloma and long-term survival presented with orbital involvement. The subject lacked the typical features and poor prognostic factors associated with multiple myeloma, such as renal failure, hypercalcemia, and paraprotein in the serum and urine. The orbital computed tomographic scan revealed the tumor encasing the optic nerve, but without prominent bony destruction. Therefore, a frontal skull craniotomy with an epidural entrance to the orbital space was performed, to completely extirpate the orbital mass. The surgical procedure was followed by moderate-dose radiation therapy. After 32 months of follow-up care, the subject is doing well with excellent local control.Although the effectiveness and applicability of this approach remains to be determined, this case report demonstrates that accurate and early detection combined with local surgical treatment and appropriate radio/chemotherapy, can be applied to effectively extend an orbital multiple myeloma patient's life. Multiple myeloma presents as a systemic, disseminated disease and represents an uncontrolled proliferation of plasma cells with the overproduction of proteins belonging to the immunoglobulin family, and accounts for 1% to 2% of all cancers [A report from the International Myeloma Working Group in 2003 [Plasma cell myeloma, or orbital myelomatosis is a rare and diverse condition, even among patients with known multiple myeloma . The difIn the current report, we present a patient with multiple myeloma who had an unusual presentation, and has experienced an extended survival after undergoing a frontal skull craniotomy followed by moderate-dose radiotherapy.The subject examined herein was a 43-year-old male factory worker. Seven years before this study was initiated, he had a motorcycle accident and experienced pain in the left hip for which he was referred to our Emergency Department (ED). A left hip intertrochanteric fracture was suspected based on radiologic observations. A curettage with internal fixation of the left femur was performed, and the pathologic report noted lobules of mature plasma cells in the bone and soft tissue. Further assessment of the condition was carried out post-surgery. A standard skull X-ray series revealed typical "punched out" osteolytic lesions. Systemic disease was considered, however, bone marrow analysis was normal and no abnormal monoclonal gammopathy was detected by serum immunoelectrophoresis. Blood analysis, including calcium level and complete blood count were normal. In addition, no serum paraprotein or urinary free light chains were detected. Therefore, non-secretory multiple myeloma was proposed and the patient received radiotherapy (5040 cGy in 28 fractions), via a linear accelerator to the site of the proximal femoral lesion after the surgical incision had properly healed.Three months after the completion of radiotherapy, the patient reported significant back pain. Whole bone scintigraphy showed an increased uptake over the thoracic spine, and a magnetic resonance imaging (MRI) study of the spine revealed multiple areas of bony destruction involving T2-T4. A laminectomy of the thoracic spine with resection of the spinal tumor was done performed (3.5 months after completion of radiotherapy). The pathologic report was consistent with a plasma cell tumor and non-secretory multiple myeloma Fig. . Post-suApproximately 2.5 years ago, the patient developed progressive proptosis and a limitation of gaze. An ophthalmologic examination at that time revealed a visual acuity of 20/40 in the right eye and 20/200 in the left eye. The left eye was noted to protrude 5 mm more anteriorly than the right eye. A computerized tomographic (CT) scan of the orbit revealed a left intraorbital mass lesion occupying the upper-outer quadrant, compressing the superior rectal muscle and encasing the optic nerve, but without prominent bony destruction Fig. .In order to expeditiously release the nerve-compression, a left frontal skull craniotomy to the midline was performed, prior to an epidural retraction of the left frontal lobe in a step-by-step fashion until the orifice of the optic canal was reached. Some tumor-like tissue was identified on the orbital roof. After removing the tumor-like tissue, unroofing of the orbit was performed. Histopathological examination of the tissue revealed bone and soft tissue with infiltrating plasma cells containing round, eccentric, hyperchromatic nuclei, consistent with a diagnosis of plasma cell tumor. At the time of surgery, the tumor was found to have invaded the orbital cavity, encased the optic nerve, and also infiltrated superiorly compressing the levator and superior rectus muscles. Further unroofing of the orbit was done to excise residual non-visible tumor ensuring total removal. Two titanium mesh patches were used to control orbital pressure. After surgery, the subject's left eye exhibited no significant exophlathesis and he reported a slightly blurred vision.® , 4 mg/month was administered during the course of radiation therapy to prevent disease progression.At follow-up one month after surgery, examination revealed markedly decreased proptosis of the eye and the subject was referred to the radiation oncology department for additional treatment The patient underwent radiotherapy to the primary orbit tumor bed, with a dose of 3960 cGy in 22 fractions. As the patient experienced did not tolerate the prior medical treatment, ZometaThe subject was followed every 2 to 4 month with examinations and visual acuity checks, and bone scans every 6 months. At follow-up examination 32 months after frontal skull craniotomy followed by moderate-dose radiotherapy, his visual acuity was 20/50 in the left eye and he had no other complaints. CT scan at that time showed post-surgery changes in the retro-orbital area and no abnormal mass tissue was noticed.Care should be taken in the diagnosis of orbital multiple myeloma, as it has been demonstrated that orbital plasmacytoma may mimic other orbital tumors such as meningioma, melanoma, and orbital carcinoma under angiography . Optic nIn the current case study examined a subject with orbital multiple myeloma. Malignant carcinoma was excluded because it is usually accompanied by prominent bony destruction and is characterized by an extended area of invasion. Neither the physical exam or laboratory findings suggested the presence of malignant lymphoma. The occurrence of an inflammatory pseudotumor was also unlikely, as no episodes of erythema involving the eyelid had occurred in this patient. The clinical findings indicated a rare case, as plasma cell tumors with orbital involvement are not often reported, even among patients with known multiple myeloma. Reports suggest that orbital involvement in patients with multiple myeloma may be a first sign of insufficient treatment or the first sign of systemic disease ,11 In adBecause multiple myeloma is a systemic, disseminated disease, chemotherapy is the preferred treatment modality. Local, aggressive treatments such as surgery are generally not used; however, in the subject examined herein, proptosis and limitation of gaze occurred over a short time period and chemotherapy was not suitable for local control, especially in the orbit area. External beam radiation therapy can achieve superior local therapeutic results when used at a relatively high dose of 5000-6000 cGy . HoweverIn our case, the subject survived for more than 84 months since diagnosis, which is nearly twice the mean survival time . Alexanind, 3rd, 4th, and 6th cranial nerves could be injured by an orbital approach, the surgical procedure allowed removal of the majority of the tumor, which substantially increased the control rate of the adjuvant radiotherapy.The surgical approach that we undertook was distinct from that followed by most surgeons ,18. We cNumerous reports describe invasion of the orbit by multiple myeloma, as demonstrated by CT scan ,18-20. MAlthough the effectiveness and applicability of this approach remains to be determined though the evaluation of its application in additional cases of orbital multiple myeloma, this case report demonstrates that accurate and early detection, currently facilitated by magnetic resonance imaging , combineWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.We declare that all the listed authors have participated actively in the study and all meet the requirements of the authorship. HLK carried out the radiotherapy, and drafted the manuscript. CLC participated in its design and coordination of the study. KHC conceived of the study, and helped to draft the manuscript. All authors read and approved the final manuscript.


The heart is an exceedingly rare site of metastatic involvement in carcinoid tumors. Only nineteen cases have been described in the literature over the past 30 years. We report here on a patient who presented with progressive carcinoid syndrome despite surgical resection of her liver metastases. She was found to have cardiac metastases on inidium-111-pentetreotide scintigraphy and subsequently underwent external beam radiation to the heart resulting in symptomatic palliation of her syndrome and objective radiographic response. To our knowledge, this is the first reported case of metastatic cardiac carcinoid treated with external beam irradiation. A 45 year-old woman with a history of metastatic carcinoid disease presented to our institution with progressive flushing and diarrhea.She had been diagnosed with a carcinoid tumor 18 months earlier when an enlarged mesenteric lymph node was discovered incidentally during laparoscopic gastric bypass surgery. Pathologic evaluation demonstrated a moderately differentiated neuroendocrine tumor. Laboratory studies revealed an elevation in 24 hour urine 5 hydroxyindoleacetic acid (5HIAA) of 37.4 mg (reference range 1–6 mg) and an elevated serum serotonin of 1671 ng/ml (reference range 22–180 ng/ml). At the time of initial diagnosis, the patient denied any prior history of flushing, diarrhea or wheezing.Magnetic resonance imaging of the abdomen revealed two hepatic masses, one in the dome of the liver measuring 6.8 cm, and another in the posterior right hepatic lobe measuring 2.2 cm. Indium-111-pentetreotide scintigraphy (OctreoScan™) revealed a focus of activity in the right hepatic lobe, as well as two foci of intense activity in the cardiac region . Moreover, the patient began developing progressive diarrhea and intense facial flushing despite dose escalation of depot octreotide from 30 mg to 60 mg every 4 weeks.Repeat indium-111-pentetreotide scintigraphy twelve months after initial diagnosis demonstrated resolution of activity in the liver. However, persistent radiotracer uptake was detected in the region of the myocardium. Echocardiography was ordered to evaluate for the presence of cardiac metastases. It demonstrated trace to mild tricuspid insufficiency and trace aortic insufficiency, but showed no evidence of an intracardiac mass.Magnetic resonance (MR) imaging of the chest was performed using multiplanar breath-hold, electrocardiogram-gated HASTE  and electrocardiogram-gated, post-gadolinium T1-weighted spin-echo images obtained on a 1.5-Tesla Symphony MR scanner . The MR images demonstrated a 3.8 × 2.1 cm mildly enhancing mass involving the free wall of the right ventricle as well as a poorly-defined mass involving the mid anterior left ventricular wall with extenstion to the apex. . Another 111Indium-pentetreotide scintigraphy.[While echocardiography has been the primary technique for identifying myocardial metastases from carcinoid tumors, other methods have also been described in the literature. Puvaneswary et al. described the use of magnetic resonance imaging for localization of cardiac metastases, while Ytigraphy. In this The location of cardiac metastases in prior reported cases has included all chambers of the heart as well as pericardium.,2,5,6 TwAn interesting feature of this case was the persistence of elevated serotonin along with progressive flushing and diarrhea despite the successful resection of liver metastases through radiofrequency ablation and normalization of urine 5 hydroxyindolacetic acid (5HIAA). Since inactivation of serotonin and its catabolism into 5HIAA occurs partially in the lung, we hypothesize that the direct secretion of serotonin into the systemic circulation by the left ventricular metastasis may have resulted in exacerbation of the carcinoid syndrome despite ablation of liver metastases.Surgical resection of cardiac metastases has been the therapy of choice in the majority of carcinoid tumors described in the literature.,2,4 A miSchupak and Wallner reviewed 44 patients with metastatic or unresectable carcinoid tumors who were treated at Memorial Sloan-Kettering Cancer Center with radiation. The siteCardiac effects of radiation have been evaluated in great detail, with data derived largely from follow-up of long term survivors of Hodgkin's disease. Current evidence has shown that radiation to the heart can be associated with pericardial disease, accelerated atherogenesis of the coronary arteries, myocardial disease, valve defects, and predisposition to conduction abnormalities.-13The heart is a rare site of involvement in metastatic carcinoid tumors. Electrocardiogram-gated MRI may be a useful imaging modality for anatomic delineation of the tumor. Carcinoid tumors involving the myocardium can produce substantial morbidity due to invasion of sensitive cardiac structures and also due to secretion of serotonin directly into the systemic circulation. When surgical resection is considered excessively risky, external beam irradiation may be an effective option for palliation of symptoms. The potential benefits need to be weighed against the risks of pericardial, valvular and myocardial toxicity as well as chronic atherogenesis.The author(s) declare that they have no competing interests.SH commented on radiation technique and safety. TH commented on radiologic modalities and interpretation. JS and LK prepared the remainder of the manuscript including clinical history and therapeutic outcome.


A cutaneous horn is a conical projection of hyperkeratotic epidermis. Though grossly resembling an animal horn, it lacks a bony core. These lesions have been well described in Caucasian patients, as well as in a number of Arabic and Asian patients.A young female presented with a large 'horn' of five-year duration, arising from a burn scar. Excision and scalp reconstruction were performed. Histology was reported as verrucoid epidermal hyperplasia with cutaneous horn.This may be the first documentation of this lesion in a black African. Although likely rare, it should be considered in the differential diagnosis of dermatologic lesions. Up to 40% of cutaneous horns occur as part of a premalignant or malignant lesion, and surgical extirpation with histological examination is thus more important than the curiosity surrounding these lesions. A cutaneous horn, or cornu cutaneum, is a dense hyperkeratotic conical projection of skin arising from an unusual cohesiveness of keratinized material. It resembles an animal horn grossly, but lacks a bony core, histologically consisting of concentric layers of cornified epithelial cells. Most have a yellow-white color, and may be straight or curved and twisted, and vary from a few millimeters to several centimeters in length ,2. CutanA 28 year old female patient presented to AIC Kijabe Hospital (KH) with a large 'horn' growing from her right parietal region. She had suffered a thermal burn of this same area at the age of 5 years. She had successfully concealed the scalp burn scar using a wig all her life Figure , until tOn examination, she had a large 15 cm × 15 cm area of alopecia over the right temporo-parietal region of her scalp. A golden-yellow colored horn with a base diameter of 3 cm and a height of 6 cm sat in the middle of the scar, with an extension of a mass of similar consistency posteriorly, measuring 5 cm by 4 cm. An area of hypopigmentation encircled this mass Figure . The lesHistology was reported as verrucoid epidermal hyperplasia with a cutaneous horn, and vitiligo. There was no evidence of malignancy.The patient was satisfied with the scalp reconstruction especially as it allowed her to do away with the use of a wig.A sizeable number of people with cutaneous horns have been reported in the medical literature, almost entirely among Caucasians from Europe -4, with Bondeson presented an excellent review of cutaneous horns. In Europe these individuals were often treated with superstitious awe and many enterprising showmen made careers out of exhibiting people with cutaneous horns for money . Yu et aBurn scars are known to heal with hypertrophic scars, keloid, skin dyspigmentation, and chronic non-healing or unstable scars which may degenerate into squamous cell carcinomas (Marjolin's ulcers), amongst other scar complications. However, there appears to be no previous mention in the literature of a cutaneous horn developing from a thermal burn scar.The present case is reported so that cutaneous horns, a common entity in the West, but a rarity in black Africans, may be considered among the differential diagnosis in dermatological conditions. The rarity of this condition also lends itself to the most unusual interpretations and superstition, as evidenced by the curious interest and discussion in the operating room at the time of this particular patient's surgery, and it is hoped that this brief report will help to correct these misconceptions. Finally, up to 40% of cutaneous horns have been shown to have an underlying premalignant or malignant lesion, hence the importance of complete extirpation and histopathological diagnosis .The author(s) declare that they have no competing interests.The corresponding author came up with the idea, performed the write up and referencing. The author takes sole responsibility of the entire content of this article.Informed written consent was obtained from the patient for the publication of this paper.


Seborrheic keratosis is a very common benign skin tumor in man. Melanoma is rare but is the most dreaded of all malignant skin tumors. A melanoma arising in a seborrheic keratosis is distinctly rare. We are reporting such a case occurring in an 86-year-old man.An-86-year-old male with a history of multiple actinic keratoses and seborrheic keratoses of the head and trunk presented with a mid-back skin lesion. The lesion was poorly circumscribed, flat, and gray, with a pink-tan, well-circumscribed scaly nodule within it. The biopsied lesion was composed of the usual features of hyperkeratotic seborrheic keratosis, but with focal atypical melanocytic proliferation with nesting along the dermal-epidermal junction. We interpreted this lesion as a melanoma in-situ arising within a seborrheic keratosis.It is not uncommon for many physicians to remove a typical seborrheic keratosis without a confirmatory microscopic confirmation. We urge that all such lesions be examined by the pathologist to avoid missing another concomitant malignant lesion such as melanoma which needs adequate resection and close follow-up. Melanoma in-situ arising within seborrheic keratosis, while reported in the literature, is still a relatively rare entity, appearing a handful of times in the literature over the past two decades -4. SeborAn-86-year-old male with a history of multiple actinic keratoses and seborrheic keratoses of the head and trunk presented with a mid-back skin lesion. The lesion was poorly circumscribed, flat, and gray, with a pink-tan, well-circumscribed scaly nodule within it. The biopsied lesion was composed of the usual features of hyperkeratotic seborrheic keratosis, but with focal atypical melanocytic proliferation with nesting along the dermal-epidermal junction Figure . These nWhile the case reported here on clinical examination showed the melanocytic  and seborrheic  components, these findings are not always evident. Therefore, histopathologic examination of all seborrheic keratoses should be considered, and is mandatory for all lesions with suspicious or changing characteristics. Lim  retrospeWhether melanoma and seborrheic keratoses are coincident lesions or whether seborrheic keratosis is a precursor lesion is not clear. The fact that seborrheic keratoses are such common lesions suggests that this co-occurrence is coincidental. However, a common tumorigenic factor within the local milieu of the dermal-epidermal junction cannot be excluded as influencing the development of both lesions.This and other similar case reports underscore the importance of pathologic examination of all skin lesions, even if clinically benign. Older individuals, in particular, develop both benign and malignant skin lesions at a higher rate when compared with younger people, making co-occurrence of diagnostically disparate entities at the same skin site more likely. While the clinical appearance of the lesion in this patient suggested the presence of more than one histopathologic diagnosis, other such cases may not by clinically apparent.The authors declare that they have no competing interests.SR drafted the manuscript, JW prepared the photomicrographs, EA reviewed the references, and DPS conceived, revised, and submitted the manuscript. All authored have read and approved the final manuscript.Written consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Vascular anomalies involving the small bowel are an uncommon cause of gastrointestinal bleeding in childhood. We present here an 11-year-old boy who presented with severe anemia and malena. The routine investigations did not reveal any pathology. A capsule endoscopy study was performed, which clinched the diagnosis and identified two intestinal hemangiomas. The hemangiomas were resected and the child recovered. Lower gastrointestinal (GI) bleeding in children is most often caused by Meckel’s diverticulum, intussusception, or necrotizing enterocolitis. VascularAn 11-year-old boy presented with history of parents noticing progressive pallor in the child with easy fatigability and weakness associated with occasional episodes of malena. There was a history of excision of large cutaneous hemangioma over left scapular region at 3 years of age at a local hospital, during which he was transfused 2 units of whole blood.The clinical examination revealed a grossly pale child with mild tachycardia and a well-healed scar over the left scapula. The general and systemic exam was within normal limits. An initial workup confirmed severe anemia with hemoglobin of 3.5 g%, hematocrit of 14% with normal platelet counts. His stool for occult blood was positive for guaiac test. He was transfused 2 units of blood, following which he underwent upper GI endoscopy and colonoscopy which were essentially normal.99 (RBC Tc99) scan indicated a small collection of blood present at the terminal ileum with no definite cause and site having been cited.A barium meal follow through also did not reveal anything abnormal, as did all the investigations, to rule out malabsorption syndrome and celiac disease. As his symptoms persisted, a selective mesenteric computed tomogram (CT) angiography was performed which only suggested a mild thickening of the terminal ileum, with no evidence of any cause of lower GI bleed. A red blood cell tagged technitiumA capsule endoscopy (using PillCam™) identified two hemangiomatous lesions at the level of mid and terminal parts of jejunum, with evidence of fresh bleed in one of the lesions Figures  and 2. ACapsule endoscopy is a technology approved by the Food and Drug Administration, USA, for its use in pediatric age group between 10 and 18 years, and invoAs the capsule travels through the esophagus, stomach, and small intestine, it takes photographs at the rate of approximately two per second. The photographs are transmitted by the radio transmitter to a small receiver that is worn on the waist of the patient undergoing capsule endoscopy. At the end of the procedure, approximately 24 hours later, about 50,000 photographs are downloaded from the receiver into a computer, and the relevant images are sorted out by the technician, whereas the capsule is passed by the patient into the toilet and flushed away.Capsule endoscopy has proven to be superior and sensitive in diagnosing lesions which may have been missed on rest of the investigations, and it is especially useful for sites between duodenojejunal (DJ) and ileocecal (IC) junction. One such pathology is angiodysplasia that can bleed intermittently. Literature is abound with case reports of small intestinal lesions such as lymphoma, carcinoid tumor, malignancies and Crohn’s disease of the small intestine, detected and treated using capsule endoscopy, as well as investigation of Peutz-Jeghers syndrome using capsule endoscopy. There haIntestinal hemangiomas are most commonly found in the mid-jejunum and may be solitary or occasionally multiple. These can present with a spectrum of clinical picture like anemia, which may be innocuous or chronic and severe, malena, abdominal pain, intussusceptions, intramural hematoma and/or intestinal obstruction with or without perforation. The diagnosis of intestinal hemangiomas is difficult and the treatment of these lesions remains primarily surgical; however, intraoperative localization is a big challenge.99scan are a relatively reliable way to diagnose and determine the location of these lesions, but their sensitivity increases if the patient is actively bleeding and thus their limitations.Barium studies of the GI tract are not very useful, whereas To conclude, this case highlights the role of capsule endoscopy in clinching the diagnosis in which other modalities were of little help.


Bezoars are uncommon findings in the gastrointestinal tract and are composed of a wide variety of materials. We report a case of a relapsing metal bezoar in a man with schizophrenia.A 34-year-old man presented with a history of sub-acute onset of mild diffuse abdominal pain and abdominal distention. Physical examination revealed dullness to percussion in the upper and lower left quadrants. Past medical history was remarkable for epilepsy, schizophrenia and previous abdominal surgery for intestinal occlusion. Plain radiographs revealed objects of metal density contained within a dilated stomach. Celiotomy was performed revealing more than 350 metal objects inside the stomach. The patient was discharged and referred to a psychiatric facility.Intestinal occlusion in patients with psychiatric disorders can result from rare causes such as bezoars. This report alerts surgeons to rule out bezoars in the differential diagnosis of intestinal occlusion in people with mental health problems. A bezoar is a conglomeration of partially digested or non-digested foreign material in the gastrointestinal (GI) tract, most commonly found in the stomach . Less coThe occurrence of relapse is rare and will reappear in 14% of cases, more often associated in psychiatric patients . Only twA 34-year-old man presented to the emergency room with sub-acute onset of mild diffuse abdominal pain and abdominal distention, accompanied with vomiting of gastric and metal fragment contents. His social history was significant for tobacco and cocaine consumption. The patient was under treatment for long-term epilepsy and schizophrenia. He had an abdominal celiotomy two years earlier for removal of foreign metal contents in the stomach. Physical examination revealed an afebrile patient with tachycardia and tachypnea. The abdomen was distended and tender to palpation without peritoneal signs of irritation. A palpable mass was felt in the upper and lower left quadrants both being dull to percussion. Liver dullness was not obliterated and rectal examination revealed an empty rectum. Laboratory tests revealed leukocytosis with left shift, other tests  were unremarkable. Plain radiographs (anteroposterior (AP) and lateral) of the abdomen showed multiple objects of metal density contained within the stomach Figure .The patient was taken to the operating room (OR) for an exploratory celiotomy through a midline incision. He was found to have a grossly dilated stomach. A longitudinal gastrostomy was made revealing multiple metal objects including: nails, copper wires, stones, plastic rosary beads and the remains of partially digested food (389 objects) Figure . After ePhytobezoar made of vegetable fibers or plant material, trichobezoar are a result of ingestion of human hair, drug-bezoar contain accumulated masses of medication, lactobezoars made of undigested milk described in premature infants and in full term infants and other less frequent materials are named miscellaneous bezoars or polybezoars [et al. [Bezoars are classified according to the materials which they are composed of (named in order of frequency): ybezoars . Gastroiybezoars . Reportsybezoars . After rybezoars  and the  [et al.  in 2005, [et al.  therefor [et al. . As in oThis entity occurs in normal stomachs caused by the ingestion of materials that cannot pass the pylorus such as plastic, metal and wooden foreign bodies. Other bezoars occur as a complication of gastric motility, usually prior gastric surgery such as vagotomy, leading to reduced gastric acidity; gastric stasis and loss of pyloric function; peptic ulcer disease/stenosis; chronic gastritis; Crohn's disease; carcinoma of the stomach, duodenum, or pancreas; dehydration and hypothyroidism ; diabetiBezoars have been known to cause a wide variety of symptoms. In the stomach, they are associated with anorexia, bloating, early satiety, dyspepsia, malaise, weakness, weight loss, headaches, and a feeling of fullness or heaviness in the epigastrium . They maIn our patient, the diagnosis was simple because there were not many options; a patient with intestinal obstruction, psychiatric disturbances, previous gastric surgery and the radiographic findings took him immediately to the OR. The gastrostomy with foreign material removal and thorough exploration of the rest of the GI tract was curative. We conclude that, in the face of an intestinal occlusion in a patient with a psychiatric disorder and a history of GI surgery, the physician must suspect, in addition to adhesions or hernias, the possibility of a bezoar.Plain and contrast enhanced radiographic studies are important for both diagnosis and treatment. It is also important to consider GI endoscopy as part of the diagnosis and treatment plan. In cases where bezoars cannot be treated by dissolving agents such as enzymes or chemicals and endoscopy is not able to remove the obstruction, surgery is the last option.Written informed consent was obtained from the patient's mother for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MRPA participated in the surgical team and the care of the patient during his hospitalization, and was also involved in drafting and review of the manuscript. FIAG made the evaluation in the emergency department, the diagnostic and treatment protocol, and the postoperative care, and also the review of the literature. SEFJ participated in the surgical team and the care of the patient, and also took the pictures, carried out the review of the literature and participated in the drafting of the manuscript. OFD and JAMH performed the case review, completed the documentation and were major contributors in writing the manuscript. AGO reviewed the case, evaluated the available literature, and made a substantive intellectual contribution to the final version. All authors read and approved the final manuscript.


Pelvic sarcoma is associated with a relatively poor prognosis, due to the difficulty in obtaining an adequate surgical margin given the complex pelvic anatomy. Magnetic resonance imaging and computerized tomography allow valuable surgical resection planning, but intraoperative localization remains hazardous. Surgical navigation systems could be of great benefit in surgical oncology, especially in difficult tumor location; however, no commercial surgical oncology software is currently available. A customized navigation software was developed and used to perform a synovial sarcoma resection and allograft reconstruction. The software permitted preoperative planning with defined target planes and intraoperative navigation with a free-hand saw blade. The allograft was cut according to the same planes. Histological examination revealed tumor-free resection margins. Allograft fitting to the pelvis of the patient was excellent and allowed stable osteosynthesis. We believe this to be the first case of combined computer-assisted tumor resection and reconstruction with an allograft. Patients with malignant neoplasms of the pelvic girdle are at a higher risk for treatment failure than patients with similar tumors located in a limb . The reaDuring surgery in complex anatomical locations , the surgeon is often lost  and lackComputer-assisted surgical navigation systems that aid in surgical precision are widely available for procedures such as total hip or knee arthroplasty, anterior cruciate ligament reconstruction, high tibial osteotomy, and pedicle screw placement in spine surgery . AdditioTo date, navigation software has never been used for simultaneous resection and allograft reconstruction. We report a case of synovial sarcoma involving the acetabular area of the pelvis (zone II and III of Enneking)  in whichA thirty-two-year-old man was referred to our department for a longer than one-year history of hip pain. Neurological deficits and systemic symptoms, such as fever or weight loss, were absent. A plain radiograph of the pelvis showed an osteolytic lesion of the ischium. Computed tomography and MRI revealed a tumor involving the acetabular area, ischium, and pubis. Further evaluation, including chest CT and PET-CT (fluorodeoxyglucose-18) showed no distant metastases. An incisional biopsy was performed and histological evaluation of the biopsy tissue was consistent with the diagnosis of grade III synovial sarcoma.Preoperative pelvic CT and MRI scans were obtained using a Brilliance 40 CT scanner  with a 1-mm spacing between slices and 2-mm slice thickness and a 1.5 T NTScan Intera MRI  with a 4-mm spacing between slices, 3-mm slice thickness, repetition time of 550 msec, and echo time of 14 msec. The open-source software ITK-Snap 1.6.0.1 (www.itksnap.org/) was used to manually segment the tumor on each MRI slice where it was visible Figures . Since MFor pelvis osteotomies, three target planes were planned to ensure resection of the whole tumor volume with a tumor-free margin. The first plane was horizontal above the acetabulum, the second was vertical in the pubis, and the third was coronal in the ischiatic tuberosity . These tTo select the best-fitting allograft among the available iliac bone allografts from the local bone bank, we performed a CT-based  registration between the iliac bone of the patient and different allografts . The selModels of the iliac bone of the patient and of the selected allograft were created by rapid prototyping  Sirris, using a A dynamic reference-base (DRB) was fixed to the iliac crest of the prototype using a rotational stabilizer and was tracked by an NDI Polaris localizer . Prototype-to-image matching was performed with a surface-based matching algorithm by palpating both the ilium and pubis of the prototype. Error of registration was verified by palpating different points of the pelvis. The saw blade was calibrated in 2D with a developed calibration frame. The three preoperatively defined target planes were marked with the navigation pointer, providing a start line for the saw . The sawThe patient was placed in the lateral position, and ilioinguinal and Kocher-Langenbeck approaches were used . After sThe DRB was fixed to the iliac crest of the chosen allograft , graft-tThe total surgery time was 13 h 4 min from the time of skin incision to the end of skin closure. Preoperative preparation took 1 h 22 min, including general anesthesia, thoracic epidural catheter insertion, patient positioning, and draping. The estimated blood loss was 4.1 L. Hemostasis difficulties were encountered close to the ischiopubic ramus due to the proximity of the corpus cavernosum.Histological examination of the removed sarcoma revealed a synovial sarcoma, and showed that all resection margins were tumor-free. The following day, the patient underwent surgery for hemostasis. The patient developed transient femoral nerve paresis, as confirmed by electromyography. The patient walked on crutches with partial weight-bearing for three months, after which full weight-bearing was allowed. A postoperative CT scan revealed perfect plane-to-plane contact between the allograft and host pelvic bone Figures .Dedicated tumor navigation software modules are nowadays available for commercial use. No specific navigation software has been developed to support both tumor resection and reconstruction with navigation of a sawblade. Therefore, we adapted the spine module of a commercially available navigation system  to enable plane navigation. Although similar adaptations have been previously reported , 11, theBoth CT and MRI are essential for tumor surgery preoperative preparation. A CT reveals precise bony details, while an MRI is superior in delineating the intraosseous and extraosseous tumor extensions, particularly in the soft tissues . For synThe CT-based registration method of allograft selection offers several advantages. First, selection of the best-fitting allograft is more efficient than when using the radiograph-based method with templates . Graft-tSurgery rehearsal with prototypes allowed us to choose the best location of the DRB, thereby increasing rigid body visibility. The target plane feasibility, determined as whether or not the saw blade could reasonably reach the target plane through the planned surgical approach, was also checked. An allograft fitting test within the patient defect showed a small gap due to bone loss related to the saw blade thickness. It was decided to move the osteotomy planes 1.5 mm back in the graft to compensate for this bone loss.Simultaneous use of ilioinguinal and Kocher-Langenbeck approaches provides improved exposure, thereby facilitating reduction and fixation in acetabular fractures , 28, tumIn computer-assisted surgeries, there are two methods of surgical planning: preoperative  and intraoperative  . IntraopMost navigation systems capable of navigating a saw blade only help in cutting block alignment. However, cutting blocks are bulky instruments. Haider et al. developed free-hand cutting with an oscillating bone saw in total knee arthroplasty. When the entire saw was registered as one rigid body, the free-hand technique was found to be 15% faster than using conventional cutting blocks. The implant fit was 400% better with the navigated free-hand bone cutting than that obtained using cutting blocks , probablWe believe this to be the first reported case of combined computer-assisted tumor resection and reconstruction with an allograft. To our knowledge, the patient-to-graft transfer of plane coordinates has never been reported. This technique allowed us to cut the allograft simultaneously (by another surgeon) or before tumor resection, since the planes were defined preoperatively, thereby decreasing the operating time. The accuracy of intraoperative identification by navigation allowed us to obtain a safe margin by avoiding unnecessary resection. This was also the first combined clinical use of a free-hand saw for both tumor resection and reconstruction. The iliac bone, tumor, target planes, and saw blade were directly visualized in 3D on a computer monitor in the operating room . For iliThe purpose of limb salvage surgery is to preserve a functioning limb. The surgery requires that the surgeon goes closer to the tumor than they would in amputation, but without increasing patient risk. Osteosarcoma studies have shown an increased risk of local recurrence in patients undergoing limb-salvage surgery, related to the excision margins and the responsiveness of the primary tumor to chemotherapy . Strict The report of this case has been approved by an ethical committee (registering no. B40320095697).The authors state that there is no conflict of interests.


Testicular neoplasms metastasizing to the retroperitoneum rarely involve the upper gastrointestinal tract. Gastrointestinal tract metastases usually present with complications including intestinal obstruction, gastrointestinal hemorrhage, and rarely ulceration of the bowel mucosa.We describe an unusual case of duodenal perforation as the presenting manifestation of metastatic classic type seminoma in a 45-year-old man.Germ cell tumor diagnosis should be considered when an ulcerating small bowel mass is identified in a young man. Non-semarcinoma . The mosarcinoma ,4. Diffearcinoma . GI comparcinoma . Althougarcinoma ,5,6. We %, and itA 45-year-old man presented with acute respiratory failure, hypotension, rigid abdomen, and a hard, erythematous, and tender 14 cm right inguinoscrotal mass. Initial differential diagnoses included incarcerated hernia and testicular cancer. Further information regarding the mass could not be elicited due to the patient's altered mental status and critical condition requiring immediate intubation. Plain abdominal radiograph was unremarkable and chest radiograph revealed two large pulmonary nodules suspicious for malignancy. The patient's laboratory findings revealed elevated lactate of 7.7 mmol/liter , amylase of 518 units/liter , lipase of 157 units/liter , a normal WBC of 5.5 with a slight left shift, and normal tumor markers . He underwent an emergency exploratory laparotomy due to suspicion of an incarcerated hernia and was found to have succus entericus throughout the peritoneal cavity and significant para-aortic lymphadenopathy invading the second and third portion of the duodenum.The perforated duodenal defect could not be repaired due to the extent of tumor infiltration. A controlled fistula was created with two separate red rubber catheters which were placed proximally and distally to the duodenal defect. A wedge tissue biopsy taken from the mass proved consistent with classic seminoma Figure . The rigThe patient remained on respiratory support throughout his hospitalization and eventually succumbed to his disease 4 weeks later when his family declined further medical therapy. Treatment with chemotherapy was considered but not commenced due to the presence of the duodenal perforation and respiratory failure.et al., pure seminoma was the histologic type observed in only two of the 21 metastatic germ cell tumors identified in the GI tract [et al. did not document any purely seminomatous tumors metastasizing to the GI tract [et al., three cases of seminoma metastatic to the duodenum and stomach were described, with severe upper abdominal and back pain having been the predominant symptoms in all patients [Involvement of the GI tract by metastatic seminoma is rare. When metastatic, only 5% of testicular germ cell tumors involve the bowel, and seminoma is the least commonly reported type of testicular neoplasm to do so . In an aGI tract . WhereasGI tract . In a reA case of an ulcerating retroperitoneal seminoma mass communicating with the distal duodenum has been reported previously . HoweverAlthough modern chemotherapeutic regimens have high success rates in the treatment of metastatic seminoma, some authors have proposed that patients with intestinal metastasis belong to a high-risk group ,7. EarlyThe authors declare that they have no competing interests.Written informed consent could not be obtained since the patient is deceased and the next of kin were untraceable. We believe this case report contains a worthwhile clinical lesson which could not be as effectively made in any other way. We expect that the next of kin would not object to the publication since the patient remains anonymous.Both authors contributed equally in preparing this document and were equally involved in care of the patient. RM was responsible for writing the introduction and case report itself, while RA contributed to the conclusion section and revision of the final document. Both authors were involved in creating CT and pathology images.


Malignancies are rare in defunctionalized bladders and are thought to arise from metaplasia secondary to chronic inflammation. Transitional cell and squamous cell carcinomas are the most common but there are three reported cases of mucinous adenocarcinoma.We report a 57-year-old Caucasian man presenting with penile discharge for 30 years following ileal conduit surgery for neurogenic bladder, and who was found to have primary mucinous adenocarcinoma of his defunctionalized bladder.Although urinary diversion without cystectomy is less common in current urologic practice, there are many patients with longstanding defunctionalized bladders. While there are no established surveillance protocols, defunctionalized bladder patients with urethral discharge should be evaluated. Primary adenocarcinoma of the urinary bladder accounts for approximately 0.5-2% of all bladder cancers . PatientPredisposing factors for the development of primary adenocarcinoma of the bladder include schistosomiasis, exstrophy, persistent urachal remnants, and bladder augmentation by intestinal segments ,2. ConcoThe potential for adenocarcinoma to develop in the defunctionalized bladder that is left in-situ at the time of urinary diversion is rare -5. We deA 57-year-old Caucasian man presented with profuse blood-streaked mucous drainage from his penis. Past medical history was significant for T12 spinal cord injury secondary to a motor vehicle accident in 1971. Due to urinary incontinence exacerbating his multiple decubitus ulcers and severe bilateral vesico-ureteral reflux, the patient underwent ileal conduit urinary diversion in 1975 with his bladder left in-situ.On initial evaluation for his penile discharge, he was found to have a right prostatic nodule on physical examination with a normal prostate specific antigen level of 1.5 ng/mL. Prostate biopsies showed mucinous adenocarcinoma in six of eight cores with large collections of mucin dissecting the prostatic parenchyma. Banal appearing columnar cells lined these mucous lakes, and nests of these cells were seen floating in the mucin (Figure Further workup included colonoscopy showing multiple adenomatous polyps were identified without invasive malignancy and cystoscopic evaluations. Cystoscopy revealed a massive amount of mucoid material within the bladder associated with a mass. Bladder washings and biopsies revealed copious amounts of mucin with associated malignant nests and single cells also consistent with mucinous adenocarcinoma. Staging evaluation revealed no evidence of metastatic disease but at the time of radical cystectomy, periaortic lymphadenopathy and a locally extensive tumor mass were identified. Palliative cystoprostatectomy was performed. The cystoprostatectomy specimen demonstrated a circumferential mass with glistening mucosal surface that involved the posterior and lateral bladder surfaces, trigone, bladder dome, and invaded the prostatic parenchyma. On histologic examination, lakes of infiltrating mucin dissected through the muscularis propria of the bladder and into the perivesicular fat Figure . The adjPostoperatively, the patient underwent adjuvant radiation and chemotherapy, but developed metastatic intraperitoneal and pulmonary masses 18 months following diagnosis. He expired 29 months after diagnosis.Historically, supravesical intestinal urinary diversion without cystectomy was a common procedure employed to control the sequelae of neurogenic bladder . AdvanceThe most common complaint of patients with defunctionalized bladders is urethral discharge, occurring in approximately 30% of patients . PatientOf the six adenocarcinomas in defunctionalized bladders, one patient had bladder dysfunction associated with prune belly syndrome , and fivAs large numbers of spinal cord injury patients with supravesical intestinal diversions approach 20 to 40 years postoperatively, malignancies in the defunctionalized bladders of these patients may become more frequent. There are currently no guidelines for bladder screening in these patients who appear to be at risk. Yap et al. recommend close follow-up with cystoscopy and bladder wash cytology on an annual or biennial basis in patients with a defunctionalized bladder . The devWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MT, PR, and JRL performed the sections, stains, and histological examination and analysis of the bladder specimen, and were major contributors in assessing the pathology literature and writing the histologic description and theoretical pathogenesis portion of the manuscript. DGM, MKT and JGH performed the surgical procedures and were major contributors in the identification of past reported cases and writing the urological and historical perspectives of the manuscript. All authors read and approved the final manuscript.


Appendicitis in femoral hernia is a rare condition, which raises diagnostic challenge.A 40-year-old man presented with painful right-sided groin swelling of 1-week duration. The area was explored, with presumpted diagnosis of inguinal abscess. At exploration a femoral hernia was found which contained a mildly inflammed appendix. Appendicectomy and hernia repair was done. Post surgical course was uneventful. We present this case with brief summary of literature pertaining to such lesions.The rare occurrence of femoral hernia containing appendix may be explained by different degrees of intestinal rotation during development or variation in its attachment to the caecum. Inflammation is due to tight femoral ring. Preoperative diagnosis is difficult. Management options are diverse.We present this case because of rarity. Early surgery prevents complications. Inflammatory swellings of the groin are common, and the changes are often attributed to infection. Although this is possible, inflammatory swellings are often secondary to groin hernia. We present an unusual case of groin swelling, outlining its investigations and subsequent management.An otherwise healthy 40-year-old male presented with a one-week history of pain and swelling in his right groin. There was no history of trauma or previous hernia, and his bowel habit was normal. On examination he had a right inguinal swelling (6 × 3 cm) lateral to the pubic tubercle. There was no evidence of a cough impulse.An ultrasound of the region was performed Figure , which sGiven the clinical findings, he was taken to the operating theatre for exploration. A standard oblique groin incision was used, and an incarcerated femoral hernia was identified. The back of the inguinal canal and the neck of the sac were opened. Inside the sac, a long, mildly inflamed appendix was found Figure . An appeth century Paris Surgeon, was the first to describe appendix in femoral hernia [The main pathologic conditions manifesting as masses in the groin fall into five major groups: congenital abnormalities, non-congenital hernias, vascular conditions, infectious or inflammatory processes, and neoplasms ,2. The hl hernia . Appendil hernia , carcinol hernia  and stoml hernia  as femorl hernia .It is very difficult to diagnose the presence of an appendix within a femoral hernial sac, and to date, only one case has been diagnosed prior to surgery. This was identified at CT scan .Tight femoral ring leads to strangulation and appendicitis. Appendicitis in a femoral hernia does not usually lead to abdominal peritonitis, due to narrow hernia sac neck which prevents inflammation of the parietal peritoneum. Clinical signs include local groin swelling, inflammation and spreading cellulitis, but often the patient feels generally well with no systemic features of sepsis, as in this case .If left untreated, the inflammation may resolve or lead to complications including abscess , necrotiDue to the rarity of such cases treatment options remain diverse. Each case should be judged separately, and treatment based on the principles of removing the source of sepsis (either operatively or by aspiration) should be employed ,14.We present a case of acute appendicitis complicating an incarcerated femoral hernia. As is often the case, the diagnosis was made at surgery. By following the principles of removing the source of sepsis and repairing the hernial defect, the patient made a safe recovery from a potentially serious condition.We present this case because of appendix in femoral hernia that too in a young male patient is very rare. Early surgical treatment prevents potential complications.A written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor in Chief of this journal.The authors declare that they have no competing interests.MP was the oncall registrar, who performed the surgery and a primary author for this manuscript. SD was the oncall consultant who was a contributor in writing the manuscript.


We describe the complete resection of a giant, well-differentiated mediastinal liposarcoma extending retropharynx to envelop the aortic arch, trachea and esophagus following preoperative radiotherapy. Liposarcomas represent only 1% of all malignancies and are commonly found in the lower limbs and retroperitoneum . SeveralA 70-year-old male with no history of radiotherapy presented with gradual swelling of the neck and dyspnea of 7 to 8 months duration. Magnetic resonance imaging (MRI) and computed tomography (CT) scans of the neck and chest revealed a large mass extending from the hypopharynx to the carina Figures  &2, causThe patient was intubated while spontaneously ventilating and with rigid bronchoscopy available. Initial bronchoscopy revealed compression of the right mainstem bronchus. Passage of an upper gastrointestinal endoscope proved difficult with compression of the esophagus. Through an initial collar incision and with rotation of the carotid sheaths laterally, a well encapsulated 11 × 4 centimeter mass was dissected from behind the hypopharynx. As it extended far into the mediastinum, a sternotomy was performed and the left and right pleural spaces opened. The liposarcoma surrounded the aortic arch, and separated the trachea from esophagus. The tumor was dissected from under the brachiocephalic artery and rotated down from the neck. Laterally, a plane was identified along the esophagus and trachea, but the lesion was too large to move between the trachea and esophagus. Consequently, a lobulated portion of the mass was divided and removed through the right chest. A final component was dissected off the distal arch of the aorta to complete the resection Figure . PostopeIn the literature, less than 150 cases of primary mediastinal liposarcomas have been reported  and becaDespite the complex nature of the anatomy surrounding mediastinal liposarcomas, surgical intervention is not unreasonable and thought to be the most effective form of treatment ,3 especiThe authors declare that they have no competing interests.TLG-J helped draft the manuscript. CRM and NRE reviewed and edited the manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Adrenal Myelolipoma is a rare benign neoplasm composed of mature adipose tissue and a variable amount of haemopoietic elements. Most lesions are small and asymptomatic, discovered incidentally during autopsy or on imaging studies performed for other reasons. Two cases of myelolipoma are presented here, where the tumours were hormonally inactive, but presented with abdominal symptoms and were managed by laparoscopic adrenalectomy. Myelolipomas are rare, benign tumours, usually found in the adrenal gland, although myelolipomatous foci can be present in other extra-adrenal locations. These tumours were initially described by Giercke in 1905, and 24 years later, Oberling coined the team ‘myelolipoma’. They are composed of mature adipocytes and normal haematopoietic tissue. Although they do not represent a hematopoietic source, they contain precursors of white and red blood cells such as megakaryocytes.[The incidence of adrenal myelolipoma is reported as being 0.08 to 0.4% at autopsy. More oft5We report two cases of symptomatic myelolipoma where diagnosis was made on the basis of radiological features and image-guided fine-needle biopsies, and were treated with laparoscopic adrenalectomy.A 53-year-old female presented with complaints of intermittent, dull aching, vague abdominal pain of few months duration. The physical examination was unremarkable. A CT scan revealed a right adrenal mass measuring 6.5 × 5.2 cm. It was labelled as a fat containing mass, raising the possibility of lipoma, fat-rich adrenal adenoma or liposarcoma. The patient was subjected to multiplanar, multisequential magnetic resonance imaging (MRI) of the adrenal glands and pre- and post-gadolinium injections, to further evaluate this mass. The findings of were consistent with myelolipoma . LaboratA 43-year-old female, known to have hypertension, presented with right loin pain, occasional palpitations and increased flushing, for the last 20 months. The physical examination was unremarkable and an ultrasound (US) of the abdomen revealed a right adrenal mass lesion. Blood and urine investigations showed the non-functioning nature of the adrenal mass. A contrast CT revealed a non-enhancing mass lesion, arising from the lateral limb of the right adrenal gland, measuring 7 × 5.4 cm, consistent with fat, and further characterisation by a multiplanar MRI with a gadolinium injection showed a 7.2 × 5.7 × 6.1 cm mass arising from the lateral limb of the right adrenal gland, composed mainly of fat. Laboratory investigations revealed the non-functioning nature of the mass, such as, adrenaline 20 ng/L, noradrenaline 217 ng/L and plasma cortisol 53.81 nmol/l. Free cortisol in 24 hours collected urine  was 187.68 nmol/L. Urinary levels of adrenaline were 20 ug/24 hours (ref: 27 ug/24 hours), noradrenaline 24 ug/24 hours (ref: 97 ug/24 hours), Dopamine 377 ug/24 hours (ref: 500 ug/24 hours) and urinary VMA was 2.2 mg/24 hours (ref: 6.8 mg/24 hours). As there was no evidence of functioning pheochromocytoma, she was diagnosed as having essential hypertension and managed with medications and no metaiodobenzylguanidine (MIBG) scan was performed. A CT-guided fine-needle aspiration cytology confirmed the diagnosis of myelolipoma. Keeping in view the large size of the mass lesion and duration of symptoms, she underwent laparoscopic right adrenalectomy. The postoperative course was uneventful.Histopathology revealed myelolipoma with extramedullary haematopoiesis measuring 8.5 × 5 × 5 cm and weighing 80 grams .Myelolipomas are small, asymptomatic and non-functional in nature. The benign nature of these lesions has been established. Nevertheless, it remains unclear how this tumour actually develops. Although the pathogenesis of myelolipomas remains speculative, the most widely accepted theory is the existence of metaplasia of reticuloendothelial cells of blood capillaries in the adrenal glands, in response to stimuli, such as, necrosis, infection or stress.Myelolipomas in our patients were found with other medical conditions, such as, hypertension, diabetes mellitus and obesity. There is no proven link between these conditions and myelolipomas, yet elderly patients undergo imaging studies for other reasons, facilitating incidental diagnosis. Occasionally there are clinical symptoms such as abdominal pain or flank pain as in our patients. Spontaneous retroperitoneal haemorrhage in association with myelolipoma has been described.Histological examination of a myelolipoma shows adipocytes with interspersed haematopoietic elements, consisting of myeloid and erthyroid precursors, as well as, megakaryocytes. When a sWe conclude that adrenal myelolipomas are rare tumours. Patients with small, asymptomatic myelolipomas must be monitored clinically for symptoms and routine follow-up imaging studies appear unnecessary for such lesions. Surgical treatment must be reserved for selected patients with large and symptomatic lesions. Occasionally large silent tumours are excised, to prevent the occurrence of a rupture or intra-tumoural haemorrhage.


Ankyloblepharon filiforme adnatum is a rare congenital anomaly. We report a case of ankyloblepharon filiforme adnatum in a newborn Caucasian male whose paediatric examination was otherwise unremarkable. Ankyloblepharon filiforme adnatum can present as an isolated finding, in association with other anomalies, or as part of a well-defined syndrome. The developing eyelid margins remain fused until the fifth month of gestation, but may not be completely separated until the seventh month . AnkylobA Caucasian male was born at 40 weeks' gestation by spontaneous vaginal delivery. The pregnancy was uneventful and the mother denied taking any drugs. The baby had bilateral partially fused eyelids at birth; paediatric assessment failed to identify any other congenital abnormalities. Ophthalmic examination revealed multiple fine bands of elastic tissue connecting the upper and lower lid margins Figure . The elaAFA was first described by Josef von Hasner in 1881, and is characterised by partial or complete adhesion of the ciliary edges of the upper and lower eyelids . UsuallyThis case report demonstrates the simplicity in treating AFA; it also highlights that its presence should alert the clinician to the possibility of an underlying congenital disorder.This case report demonstrates the simplicity in treating AFA; it also highlights that its presence should alert the clinician to the possibility of an underlying congenital disorder.AFA: ankyloblepharon filiforme adnatum.Written informed consent was obtained from the patient's parent for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AMG was the major contributor in writing the manuscript. MSM contributed to editing the manuscript and accompanying image. All authors read and approved the final manuscript.


Edward's syndrome (trisomy 18) is a rare entity with a reported incidence of 1/3000 to 1/7000 births. Less than 10% of patients survive beyond the first year of life, which may influence the fact that malignant tumors are rarely reported in association with this syndrome.The authors report a rare case of a 6-month-old girl with trisomy 18 and multifocal hepatoblastoma. The course of the disease, autopsy results and review of the literature are presented.Our case represents the seventh published case of hepatoblastoma in a patient with trisomy 18. All of the seven published cases were women, possibly due to the high preponderance of females among the children with Edward's syndrome and longer survival of females with trisomy 18 compared to males. Since both trisomy 18 and hepatoblastoma are rare conditions, the probability that a child with trisomy 18 will independently develop a hepatoblastoma is very low. Therefore, we believe that the existence of these cases in children with trisomy 18 indicates a significant association. It can be assumed that trisomy 18 potentiates the development of hepatoblastoma. Careful clinical and post-mortem studies are needed to recognize the real frequency of hepatoblastoma in children with trisomy 18, who might die from different causes with unrecognizable hepatoblastoma. Edward's syndrome (ES) was first recognized as a specific entity in 1960 by the discovery of the extra 18 chromosome in babies with a particular pattern of malformations ,3 and thHepatoblastoma (HB) sometimes occurs in patients with congenital malformations , particuWe present a child with ES who developed HB at the age of 6 months.A female, Caucasian, newborn girl was born to a 28-year-old mother after her first pregnancy at 38 weeks of gestation. The pregnancy was uneventful, except for colpitis, until the 29th gestational week when intrauterine growth retardation was noticed. The infant birth weight was 1630 g, birth length was 43 cm, and head circumference was 32.5 cm. The family history was unremarkable. The child had prominent occiput, micrognathia, high palate, low-set ears, overlapping fingers of both hands, bilateral preauricular adnexes and a red pedunculated tumor on the left cheek, diagnosed as a hamartoma. Hypotonia, absent swallowing reflex and abnormal spontaneous movements were observed. Chromosome analysis of the peripheral blood cells revealed 47,XX,+18 chromosome. Echocardiography and abdominal ultrasound examination were normal, while the ultrasound of the head revealed agenesis of the corpus callosum. Due to respiratory failure after birth, she was artificially ventilated for 2 weeks. Thereafter she was nursed at home, nourished through a gastrointestinal tube and her clinical course was uneventful. At the age of 6 months, after she had been treated for a urinary tract infection, hepatomegaly was noticed. Abdominal ultrasound revealed three well-defined hepatic masses. The largest one was 8.3 × 5.6 × 9.6 cm in size, and the two smaller masses were approximately 3.2 and 3.7 cm in size. Only a minority of the liver parenchyma appeared normal. Hepatoblastoma was confirmed by fine needle aspiration biopsy and an increased level of α-fetoprotein (51542 IU/mL). Pulmonary X-ray was normal. The infant was not treated for the tumor in accordance with the parents' decision. She was nursed at home and only analgesic drugs were given.One month later, she was admitted to hospital due to restlessness, vomiting and cough for the previous 4 days. She was in pain, febrile, icteric and protected her left arm. Hypercalcemia  and fracture of the left humerus were observed. She was treated with intravenous bisphosphonates, analgesics and the left arm was immobilized. In the following hours, she became progressively dyspnoic and died on the next day.At autopsy, the liver 741 g) was almost completely overgrown with a multicentric tumor. The largest mass measured 10 × 9 × 8 cm (Figure  g was alNeoplasias are uncommon in ES, possibly due to the high mortality in the first year of life. Nevertheless, there are reports of one neurogenic tumor  and at lCongenital abnormalities have also been recognized in patients with HB -13] whi whi13] wet al..The liver tumors were resected in three cases; two patients were alive with no evidence of recurrence at 3 and 4 years of age ,19, the et al.[Our case represents the seventh published case of HB in trisomy 18 and, together with the unpublished case mentioned by Bove et al., represeet al.. Since bHB: Hepatoblastoma; Trisomy 18: Edward's syndrome.Written informed consent was obtained from the parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.LK and JJ were treating physicians and wrote the manuscript. ZO did the autopsy and described autopsy results, pathological description and did the figures.


Amyloidosis is a disease characterized by the deposition of altered proteins in tissues. Amyloid deposition always occurs in the extracellular matrix and presents a fibrillary conformation. Local deposition of amyloid may occur in individual organs, without systemic involvement. We report here a rare case of localized penile shaft amyloidosis--an unusual location for amyloid deposition--presenting as a penile mass that resulted in a urethral stricture in 37-year old male patient. We have also comprehensively reviewed the literature regarding localized amyloidosis. Amyloidosis is a disease characterized by the deposition of altered proteins in tissues that shows the following characteristics: beta-pleated sheet molecular configuration with affinity to Congo red dye, fibrillar ultrastructure, and presence in the extracellular matrix leading to hardening of the affected tissues. Depending upon its extent, amyloidosis can be classified as systemic or localized disease. The reason for localized deposition is unknown, but it is hypothesized that such deposits result from the local synthesis of amyloid proteins rather than the deposition of light chains produced elsewhere. Isolated localized amyloidosis has been reported in almost every organ system. The localized form presents minor clinical manifestations as compared to the extensive organ involvement observed in systemic disease, and local amyloidosis may not be progressive . WorldwiA 37-year-old Asian male patient attended our clinic for evaluation of voiding difficulty and a tender mass at the distal urethra. His nationality is Korea. His chief complaint was discomfort on erection and during voiding. Physical examination revealed a tender mass in the penile shaft. His past, personal, and family history were unremarkable.Urinalysis was normal and urine cytology did not reveal any atypical cells. Blood cell count, blood biochemical investigation and urine culture were normal. Serologies for human immunodeficiency virus and syphilis were negative. A retrograde urethrogram (RGU) assess the presence of a urethral stricture; it revealed a stricture at the level of the bulbous urethra Figure. . The patThe term amyloidosis refers to a group of disorders characterized by the extracellular accumulation of insoluble, fibrillar proteins in various organs and tissues . AmyloidIn our case, the patient did not exhibit any clinical or laboratory evidence of systemic disease, suggesting the local production of amyloid protein. Moreover, as occurred in our case, localized amyloidosis in the penile area should be considered among the differential diagnoses of urinary tract obstruction.In conclusion, we have reported here a very rare case of localized amyloidosis presenting as a penile mass that manifested as a urinary tract stricture and that was confirmed by tissue biopsy. To the best of our knowledge, this is the sixth case of genitourinary tract-localized amyloidosis and the first case in Korea presenting with a penile mass that resulted in a urinary tract stricture. A consideration of localized amyloidosis of penile area should be considered in cause unknown urinary obstruction cases. Further study of localized amyloidosis may be warranted for elucidating the underlying pathophysiology of localized amyloidogenesis, which could provide a greater understanding of this disease as well as point toward its treatment.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.HK analyzed and interpreted the patient data regarding the hematological disease. JHL was a major contributor in writing the manuscript. All authors read and approved the final manuscript


Inflammatory fibroid polyp is a rare condition of the gastrointestinal tract which can lead to intestinal obstruction.We present a case of a 65-year-old woman presenting with a 1-month history of intermittent generalised abdominal pain. Computerised tomography imaging demonstrated intussusception of the small bowel. Histology of the resected small bowel revealed an inflammatory fibroid polyp with evidence of chronic ischaemia related to repeated intussusception. This rare complication of inflammatory fibroid polyps is reviewed.Although computed tomography is useful in confirming an anatomical abnormality, final diagnosis requires histopathological analysis. Operative resection of the affected segment is recommended. Inflammatory fibroid polyp (IFP) is a rare condition of the gastrointestinal tract. It is a benign solitary or sessile lesion, with an inflammatory basis, originating from the submucosa . IFPs ocA 65-year-old lady was admitted with a 1-month history of intermittent generalised cramping abdominal pain with anorexia, weight loss (10 kg), vomiting and loose bowel motions. There were no systemic symptoms of fever, sweating or rigors. Apart from a past history of hypothyroidism and hypertension there was no other significant history and she was a non-smoker. There was no family history of gastrointestinal diseases.9/litre and a C-reactive protein level of 98.5 mg/l. A provisional diagnosis of sub-acute intestinal obstruction was made.On examination, she was comfortable but dehydrated. She had a heart rate of 107 beats per minute, a blood pressure of 157/84 mmHg and a temperature of 37.2°C. The abdominal examination was unremarkable and bowel sounds were normal. Abdominal X-ray demonstrated multiple air fluid levels but no dilatation of the small bowel or colon. Haematological analyses confirmed a haemoglobin level of 12.4 g/dl, white blood cell count of 8.5 × 10The patient failed to settle with conservative management. Repeat abdominal X-rays confirmed an abnormal air-fluid level mainly in the right upper quadrant. A contrast-enhanced computed tomography (CT) scan demonstrated a mass arising from the pelvis with a tubular appearance consistent with small bowel intussusception and mucosal oedema. There was mild dilatation of the ileum proximal to the level of the intussusception with a 'telescoping' appearance of the small bowel intussusception distal to this area Figures  and 2.A midline laparotomy confirmed an intussusception approximately 30 cm proximal to the ileocaecal valve with a firm mass at its lead point. The affected bowel segment was irreducible and non-viable. A 30 cm segment of non-viable small bowel was resected and an end-to-end single layer sero-submucosal anastomosis was performed.Macroscopically, the resected ileal segment contained a 3.5 cm ulcerated pale polypoidal mass 4 cm from the nearest resection margin. The adjacent mucosa demonstrated extensive ulceration, fissuring and incipient necrosis of the wall which was in keeping with chronic ischaemia related to repeated intussusception. Histopathological examination of the polyp revealed an ulcerated polypoidal mass with florid connective tissue proliferation arising from the submucosa and inner muscularis with distortion and reaction of the overlying serosa. Furthermore, there were cytologically bland spindle cells, lymphocytes and eosinophils in the background. There was no evidence of malignancy or necrosis.The patient's postoperative recovery was uneventful and she was discharged 9 days after surgery. She remains well 20 months later with no further gastrointestinal symptoms.Only 5% to 16% of all cases of intussusception occur in adults and most surgeons will encounter only a few cases during their careers ,3. Less Plain film radiographs are performed to assess the degree of obstruction and may reveal the presence of free air in keeping with a perforation . Barium An IFP is a rare, benign, solitary polypoid or sessile lesion which was first described by Vanek in 1949 as a "gastric submucosal granuloma with eosinophilia" and has also been called an inflammatory pseudotumour and eosinophilic granuloma . It arisClinical presentation is determined by the anatomical location. IFPs arising within the stomach produce symptoms of pyloric obstruction or anaemia while those within the small bowel present with obstruction or intussusception . AlthougIFP of the ileum causing intussusception has been reported previously ,5,10,11.Recurrent intussusception secondary to IFPs of the small intestine presents a diagnostic challenge with the potential to cause bowel obstruction, necrosis and subsequent perforation. We have presented a rare complication of IFPs related to repeated ischaemic episodes from an intussusception. Although CT is useful in confirming an anatomical abnormality, final diagnosis requires histopathological analysis. Operative resection of the affected segment is recommended.The authors declare that they have no competing interests.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.AMO was involved in the literature review, manuscript preparation and manuscript editing. MEO was involved in the conception of the report, literature review, and preparation, editing and submission of the manuscript. MM was involved in the literature review, manuscript preparation and manuscript editing. KT was involved in the critical analysis of radiological imaging in the case report and manuscript review. JL was involved in the manuscript editing and manuscript review. AW was involved in manuscript editing and manuscript review. All authors have read and approved the final manuscript.


Colonic intussusception is a rare congenital abnormality, mostly manifesting before the age of two with abdominal pain and acute intestinal obstruction with or without bleeding. In adults it may occur idiopathically or due to an intraluminal tumor mass.A 25-year-old man presented with an acute abdomen and severe crampy abdominal pain. The clinical picture mimicked acute appendicitis. Transabdominal ultrasound examination revealed a 5 cm circular mass in the right upper abdomen. The ensuing computed tomography suggested an intussusception in the ascending colon. Intraoperatively, no full thickness invagination was detected. Due to a hard, intraluminal tumor a standard right hemicolectomy with ileotransversostomy was performed. The histopathological analysis revealed a cystic colon duplication leading to mucosal invagination and obstruction.In adults, colon intussusception is a rare event causing approximately 1% of all acute intestinal obstructions. Unlike its preferentially nonsurgical management in children, a bowel intussusception in adults should be operated because an organic, often malignant lesion is present in most cases. Colon intussusception and gastrointestinal duplications are diseases of young children occurring and/or becoming symptomatic usually within the first two years of life. The most typical site for colon intussusception is the ileo-ceacal region; similarly, gastrointestinal duplications most commonly affect the ileum. Surgery in case of intussusception is indicated, if bowel segments are at risk to become necrotic, with impending perforation and subsequent peritonitis . GastroiA 25-year-old man presented with an acute abdomen with abdominal defence and rebound in the right lower quadrant and with severe crampy abdominal pain. The patient reported of blood mixed stool within the last four days. There was no history or family history of inflammatory bowel disease. A transabdominal ultrasound examination revealed an unclear circular mass with 5 cm diameter in the right upper quadrant. The subsequent CT-scan showed an invagination of the ascending colon with rectal contrast enema passing no further Figure ; there wIntraoperatively, there was a firm intraluminal mass palpable in the ascending colon. A standard non-oncological right-hemicolectomy was performed. Intraoperative opening of the specimen revealed a circular, mucosa covered intraluminal mass acting as the leading point that caused partial mucosal invagination and obstruction. The stool filled saccular lesion had ulcerous areas visible on the mucosal surface Figure . Since tColon intussusception mostly occurs in children up to two years of age (boys to girls ratio: 3 to 1) due to intermittent changes in bowel motility. Although it may happen in any segment of the bowel, the most typical site is the ileo-ceacal region. Early symptoms of bowel obstruction include nausea, bilious vomiting, and intermittent moderate to severe cramping abdominal pain. Later symptoms include trans-rectal bleeding, or stool mixed with mucus and blood. Palpation of the abdomen may show a mass in the region of the punctum maximum of pain. Due to intussusception, segments may become necrotic, which can lead to bowel perforation and peritonitis [Gastrointestinal duplications are uncommon congenital abnormalities that manifest before the age of 2 years in 80% of cases. Ileal duplication is the most common one, while colonic duplications, either cystic (>80%) or tubular, occur in 10%-15% of cases and remain asymptomatic and undiagnosed in most instances. Symptomatic colonic duplication is a rarity in adults. The most common clinical symptoms are abdominal pain and intestinal obstruction. Sometimes, duplications present with signs of acute abdomen or acute bleeding, necessitating emergency surgery [Both events are unusual especially in adults, the combination of both is even more uncommon ,5. AdultIn the reported case we chose to operate the patient because of the clinical presentation with an acute abdomen. The definitive diagnosis of colonic intussusception and duplication could not be made preoperatively. The acute symptoms of  obstruction were lasting for already 4 days, so that the risk of perforation was high. Unlike in children with a high incidence of idiopathic intussusception, in adults intussusception is often the first symptom of a malignancy. Thus, in up to 50% of colonic intussusceptions in adults, the colonic lesions are malignant (adenocarcinoma), so the definitive treatment should be oncological surgery with the resection of the affected bowel segment ,8. A nonIn conclusion, bowel intussusceptions and gastrointestinal duplications are rare but have to be kept in mind in the differential diagnosis of an acute abdomen in adults. As in every abdominal mass lesion, an underlying malignancy has to be considered. Therefore an oncological operation should be planned, especially for right-sided lesions, since in this location oncological resections can be performed without impairment of postoperative bowel functions or increased morbidity.There was no financial competing interest for any of the authors, as well as there was no non-financial competing interest .CR-E, JK designed and initiated the study. CR-E, ME, JK performed a literature search. EU performed the radiological analysis. JN performed the pathological analysis. CR-E, ME, JK drafted and wrote the manuscript; EU, JN critically revised the manuscript. All authors read and approved the final version of the manuscript and agree with the manuscript's results and conclusions.Written consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/10/19/prepub


Lateral abdominal wall haematoma after blunt trauma that require surgery is rare. They usually present with pain, bruising and swelling after trauma.We report a case of a fit and healthy young girl who developed a large lateral abdominal wall haematoma following blunt trauma. Initially the haematoma was managed conservatively, however in view of increasing size surgical removal was undertaken. Post operatively the patient developed a small seroma and which was subsequently drained under ultrasound guidance. A thorough review of the literature has identified there are various options of treatment for patients with lateral abdominal wall haematoma. We conclude that management of giant traumatic lateral abdominal wall haematoma can be challenging, some will eventually need surgical intervention. Although the majority of haematoma of the lateral abdominal wall after blunt trauma are managed conservatively, some may need surgical management. We present a case of post-traumatic lateral abdominal wall haematoma that increased in size over few months after the initial injury and eventually required surgical excision.A 21-year-old healthy young girl suffered a ski-ing injury to her right flank. She is a non-smoker and does not have any significant medical or family history. An ultrasound scan performed three months after the accident showed a large subcutaneous haematoma in right posterior paraspinal region. There was no significant Doppler flow in that area. She was initially managed conservatively. The haematoma appeared to increase in size and she subsequently had a CT scan, which showed a 13 × 10 × 20 cm well defined low density cystic mass occupying the right flank and descending posteriorly to involve the gluteal muscles and upper thigh. The swelling had fine septations but was otherwise uniform in echo density and there was no infiltration into the deep muscular layers. The features were consistent with a resolving haematoma with no evidence of acute haemorrhage. Her routine haematological investigations including haemoglobin on admission were within normal limits. She was investigated for bleeding diathesis and there was no evidence of one. There was no family history of bleeding diathesis.An attempted aspiration under local anaesthesia was unsuccessful. In view of the increasing swelling and discomfort an MRI scan of the abdomen and pelvis Figure  and 2 waAll features were in keeping with a large sub-fascial organised haematoma. The source of bleeding was probably disrupted sub-fascial veins from the force of blunt trauma. In view of the ongoing pain and disfigurement the haematoma plus organised capsule was evacuated and excised enbloc. 1.5 litres of old blood was evacuated from the organised haematoma Figure . Two sucHaematomas of the abdominal wall can be divided in the common rectus sheath haematomas and the less frequent lateral abdominal wall haematomas. Rectus sheath haematoma can develop spontaneously in patients with severe hypo-coagulability such as haemophilia, von-willebrand disease or sometime anticoagulant therapy. It is also a rare complication of pregnancy, laparoscopic cholecystectomy or even abdominal insulin injections . SpontanLateral wall haematomas are uncommon and there are few reports or studies. They are classified into two groups- slow growing (oozing from muscle surface/venous bleed) and rapidly growing  haematoma. Lefere et al  reportedDiagnosis can be made clinically by obvious swelling/bruising or may be non-specific findings like chronic anaemia, fever and plural effusion . ImagingThe majority of haematomas can be treated conservatively. CT and MRI provide accurate information with regards to characteristics of the haematoma. There may be role for angiography (with or without embolisation) in patients with an acutely expanding haematoma with arterial bleed causing haemodynamic instability ,6,7. SloThe majority of haematomas resulting from blunt trauma in our experience are managed conservatively. In the acute setting, our indications for an intervention, either radiological or surgical would be an acutely expanding haematoma with suspicion of underlying major vessel injury associated with haemodynamic instability. Our experience with this case suggests initial conservative management is feasible if the patients are haemodynamically stable. However, during follow up a low threshold for surgical intervention is recommended for un-resolving haematomas. A combination of investigation (CT/MRI) and interventions  are required to ensure complete resolution of these haematomas.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SD collected the data including images, performed literature search and drafted the manuscript. PS reviewed the literature and revised the draft critically. MLJ revised and approved the final version of the manuscript. All authors read and approved the manuscript.