Spontaneous free perforation of the small bowel is unusual. There are many causes of spontaneous small bowel free perforation such as: immune-mediated or inflammatory, infections, drugs and biological agents, congenital, metabolic, vascular and neoplasm.A severe adverse effect of antipsychotic drugs is intestinal ischemia, which could lead to perforation.The authors report the clinical case of a 42-year-old schizophrenic patient, smoker, medicated with clozapine 600 mg per day, admitted to the emergency room with diffuse abdominal pain. On physical examination the patient presented abdominal rebound tenderness and peritoneal sign with raised inflammation markers and the abdominal tomography revealed pneumoperitoneum.An emergency laparotomy revealed multiple jejunal and ileal perforations.The patient was subject to small bowel resection complicated with anastomosis dehiscence, respiratory tract infection and intra-abdominal abscess.Histologic specimens showed nonspecific inflammatory findings with ischemia.The main infectious, inflammatory, congenital, auto-immune and vascular causes of spontaneous perforations were excluded.Spontaneous free perforation of the small bowel is uncommon. An intestinal ischemia might be a rare adverse effect of antipsychotics. However, only colon perforations due to ischemic colitis are described in the literature. While diagnosis of the precise cause might be challenging, and after excluding other causes, these perforations may be attributed to an adverse effect of clozapine.The cause was attributed to clozapine as the other etiologies were excluded. The clozapine’s reintroduction is controversial. In this case the clozapine dose was reduced successfully. There aThe pre-operative diagnosis is difficult and sometimes it remains challenging postoperatively.First and second generation antipsychotics commonly cause mild gastrointestinal hypomotility and rarely intestinal ischemia and necrosis. Most cases are related to phenothiazines and more recently several cases have been reported with clozapine, an atypical antipsychotic with antimuscarinic activity ,3.The risk of developing ischemic colitis increases when anticholinergic drugs are associated .In this study, a case report of spontaneous small bowel perforations is presented.This work has been reported in line with the SCARE criteria .2A 42-year old obese, smoker and schizophrenic male was medicated with 600 mg of clozapine per day. He was admitted to the emergency department with a 2 week history of diffuse abdominal pain, abdominal distention, anorexia and semi-liquid stools. On physical examination he had 110/63 mmHg of blood pressure, he was tachycardic (heart rate = 112 beats per minute), febrile (temperature = 38.5 °C) and presented abdominal tenderness and peritoneal sign.9/l, C-reactive protein >32 mg/dl) and a renal insufficiency .Laboratory investigations showed a hemoglobin of 13.6 g/dl, an increase in inflammatory markers  in the anti-mesenteric border of the distal jejunum and ileum were identified. Purulent peritonitis was present. A small bowel resection of 1.5 m was done  .Figs. 3On the second day of the postoperative period, an anastomosis dehiscence was registered. A subsequent re-laparotomy was needed. An anastomosis and caecum resection was done with the creation of an end-ileostomy and a colostomy. During hospitalization he had a respiratory tract infection which was treated with broad-spectrum antibiotics and an intra-abdominal abscess which was treated with percutaneous drainage. On the 28th day of hospitalization the patient was discharged.Histologic specimens revealed non-specific inflammatory findings with ischemia.The investigation was carried out with microbiologic cultures, serologic tests, laboratory tests, endoscopic exams with biopsies and other diagnostic exams. The main causes of spontaneous small bowel perforation were excluded, such as, infectious , immune , congenital , vascular and neoplastic.The dose of clozapine was reduced because the suspension was not viable and a restoration of the bowel continuity was done ten months later.3The main causes of spontaneous small bowel perforation were excluded, such as, infectious , immune , congenital , vascular and neoplastic .Some possible causes described in the literature as the cause of multiple small bowel perforations  were alIntestinal ischemia, in particular, ischemic colitis is an uncommon adverse effect of antipsychotic agents, more commonly found with phenothiazine drugs and atypical neuroleptics such as clozapine. Clozapine is the atypical antipsychotic drug most commonly described in the literature as the cause of ischemic colitis .An explanation for induced gastrointestinal necrosis is their antimuscarinic activity, especially when associated with other antipsychotropic drugs . The hypAnother ischemic mechanism could be attributed to the effects of antipsychotics on dopamine. In fact, dopamine could improve the mesenteric perfusion because of its vasodilatory effects at low dosage. The inhibition of dopamine-dependent mesenteric vasodilation, due to the antidopaminergic effect of antipsychotics, could play an additional part in digestive ischemia .2 and 5HT3 receptors which lead to reduced intestinal peristalsis, mucosa secretions, nociception and possibly intestinal sensitivity to distension. At its worst it could result in intestinal perforation [Antiserotoninergic properties of clozapine could also explain gastro-intestinal complications. Clozapine antagonize 5HTforation ,10.Besides clozapine, there are other risk factors described in the literature for intestinal ischemia .The intestinal perforation due to clozapine is rare and only colonic perforations are described in the literature ,3,11. ThIn this case, there was no association of antipsychotic drugs, besides clozapine, as described in the literature . The onlHowever, clozapine perse could induce ischemia by antimuscarinic, antidopaminergic and antiserotoninergic activity (described above). This intestinal ischemia caused by these three mechanisms could be in small bowel and could explain the multiple punctiform perforations presented in this case report.When other medication is not effective, the reintroduction of clozapine after severe adverse drug effects is a clinical dilemma. There are few positive case reports regarding the reintroduction of clozapine after severe gastrointestinal adverse effects. However, after intestinal perforation, there is only one case report described, where the clozapine dose is reduced . Here, i4Intestinal perforation is a rare adverse effect of clozapine. This complication can affect young patients taking psychotic drugs.The occurrence of non-specific clinical symptoms such as abdominal pain with vomiting and/or diarrhea should be taken into account. Clozapine’s suspension is recommended, but in special cases, dosage reduction seems to be safe. Howbeit, more studies are needed.There are no conflicts of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This study is exempt from ethical approval in my institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Ana Rodrigues – care of the patient, study concept and written the article.António Duarte- responsible surgeon, review article.Adriano Marques, Mariana Magalhães – care of the patient, review article.Ágata Ferreira, Isabel Dionísio – participated in surgery, review article.Rita Camarneiro, Regina Silva, Luis Val-Flores, Margarida Brito e Melo – review article.In accordance with the Declaration of Helsinki 2013, all research involving human participants has to be registered in a publicly accessible database.  Please enter the name of the registry and the unique identifying number (UIN) of your study.Ana Rodrigues.Not commissioned, externally peer reviewed.


We present a case of a 30-year-old man who had a 3-year history of low back pain.MRI demonstrated an infiltrative mass, affecting the vertebral body and pediclesof L4, with some extension to the vertebral canal. There was also tumor invasionin the inferior vena cava and in the left iliopsoas muscle. Theanatomopathological examination of the resected L4 vertebral body was of amalignant neoplasia compatible with mesenchymal chondrosarcoma . About 2 months after surgery, he developed a progressivebladder incontinence, bilateral leg weakness and severe back pain. A new MRI wasobtained, confirming progression of the disease. An occipital scalp lesion wasdetected and biopsy confirmed cutaneous metastasis. Primary malignant bonetumors are rare but should be ruled out in young patients with persistent lowback pain. We present a case of a confirmed mesenchymal chondrosarcoma affectinglumbar spine, with MRI and pathological illustrations. Early diagnosis mayimprove the chances of local disease control and even cure.  Vertebral bodiesare affected in 15% of cases.5Metastases are the most frequent bone tumors (reaching about 25% of cases).4 Here, we present a case of a young patient with a high-grade chondrosarcomaof the mesenchymal type.A high level of suspicion is necessary since these tumors are rare, especially inyoung patients with low back pain. Symptoms of secondary low back pain should beconsidered, such as pain at night, loss of weight, refractory pain, neurologicalinvolvement. MRI should be considered for investigation.A 30-year-old male patient was examined in our outpatient clinic with a 3-yearhistory of mild low back pain. In the last 20 days, the pain worsened severely, withirradiation to the posterolateral aspect of the lower limbs and difficulty to walk.Palpation of the lumbar spine sacroiliac joints was painful (positivePatrick’s test). Laboratory analysis showed normal levels of inflammatorymarkers .The patient was a heavy smoker, with no other comorbidities. Initial MRI demonstratedan infiltrative mass, affecting the vertebral body and pedicles of L4, withextension to the vertebral canal, with heterogeneous enhancement after contrastadministration . Tumor eCT scan was also performed . TherewThe patient underwent a needle transpedicular biopsy of the vertebral lesion and amalignant infiltrative bone neoplasm was diagnosed, with chondroid differentiationand several areas of necrosis.Three weeks after the needle biopsy, a posterior lumbar approach was performed, withinstallation of pedicle screws at L3 and L5 and the posterior elements were removed.The anterior large vessels were dissected from the spine and an “enbloc” resection of L4, reconstruction of the lumbar spine with a titaniumcage and antero lateral plate were done.Histopathological examination of the resected L4 vertebral body revealed aninfiltrative malignant biphasic neoplasia composed of ample ill-defined areas ofatypical cartilage with well to moderate differentiation intercepted by a variablequantity of poorly undifferentiated small cells with prominent capillaryvasculature, exhibiting hemangiopericytoma-like features . InvolvePatient was discharged after 10 days of the main procedure with controlled pain andable to walk without assistance. He was seen in our outpatient facility after 20days with moderate back pain and normal neurological examination. About 2 monthsafter the spinal reconstruction, he developed a progressive bladder incontinence,bilateral leg weakness and severe back pain. A new MRI was performed  confirmiAfter 5 months of hospital discharge, the patient underwent PET-CT, which showedprogression of the disease, characterized by metastatic implants in the skin andsubcutaneous  muscles , in bones and in liver. Thus, palliative treatment was indicated with radiotherapy.7 Some risk factors, such as malignant transformation of chondromas andassociation with hereditary multiple exostoses were not observed in our patient.Epidemiologically, spinal chondrosarcoma is more common in Caucasians (with no genderpreference), young (mean age 33 years), with a peripheral and lumbar spine location.8This patient had a previous history of low back pain but did not undergo properclinical radiological evaluation. New and persistent back pain of more than 3 monthsshould be investigated preferentially with MRI.T1 weighted images show low to intermediate signal intensity, withenhancement that varies from homogeneous to heterogeneous, sometimes with ring andarc pattern).4 Currently, there are no radiographic features able to differentiate thedifferent histological types of chondrosarcoma, such as mesenchymal,myxochondrosarcoma or a cartilage containing meningioma.9Considering radiological evaluation of vertebral body sarcomas, CT scan is the bestmethod to detect the matrix mineralization  and it can also evaluate aggressive features . MRI is better to evaluate theextension of the sarcomas  and thenature of the lesion  and brachyury.11 There are several other diseases that can be considered in the differentialdiagnosis of spine chondrosarcoma, such as angioblastic meningioma, osteosarcoma,Ewing’s sarcoma,12 A wide representation of the lesion is recommended, as well as attention todetect the undifferentiated component between larger cartilaginous areas of thetumor. Diagnosis of osteosarcoma needs confirmation of neoplastic osteoid among the cartilage.10 On the other side the nonchondroid part of a mesenchymal chondrosarcoma cancause confusion with Ewing’s sarcoma and related tumors, small cellosteosarcoma, as well with embryonal rhabdomyosarcoma and malignant lymphomainvolving bone.12 None of these tumors usually presents cartilage, except as foci of metaplasiain Ewing’s Sarcoma.12Microscopically, a bimorphic pattern is characteristic of mesenchymal chondrosarcoma,but when this tumor is formed by predominantly mature cartilage and minimal atypiaof the chondrocytes, it can be mistaken for benign cartilage lesions, ormisclassified as a well-differentiated conventional chondrosarcoma or chondroblastic osteosarcoma.12 However, it is not totally specific, because SOX9 can be found in anyneoplasm of cartilaginous lineage. The lack of FLI1 expression can be used as anadditional biomarker to differentiated between mesenchymal chondrosarcoma andEwing’s sarcoma. Also, positivity for the break-points and fusion genesinvolving EWSR1 is typical only for this last tumor.12 A promisor HEY1-NCOA2 fusion genes were identified in mesenchymalchondrosarcoma and are absent in other chondrosarcoma subtypes.13 Rhabdomyosarcomas and lymphomas involving bone can be excluded by the absenceof their respective skeletal muscle and lymphoid biomarkers.12The immunohistochemical markers employed include S-100 protein, which is typicallyexpressed only on cartilaginous areas of the mesenchymal chondrosarcoma. CD99/MIC2protein is confined to small cell component but is also demonstrated in these othersmall round cell tumors. A valuable marker, as SOX9, shows nuclear positivity inboth areas, but mainly on the immature component (chondroprogenitor cell’sphenotype) of mesenchymal chondrosarcoma, differentiating it from other small cell tumors.12Finally, hemangiopericytoma and other primary spindle cell malignant tumors, mainlywith hemangiopericytomatous vasculature, that arise in bone, must be considered indifferential diagnosis, but none show the cartilaginous components that are presentin classical mesenchymal chondrosarcomas.Therefore, the present case was confirmed by anatomopathological andimmunohistochemical analysis, after clinical and radiological suspicion.10 However, late diagnosis may limit a curative procedure, once local or distantdissemination will occur with disease progression, such as in the presentedcase.Considering treatment of primary spinal tumors, the best option is total surgicalresection, with vertebrectomy and spinal reconstruction, for isolated lesions. Inthe case of these tumors, specifically, radiotherapy and chemotherapy have nosignificant effect, and therefore are not part of the standard treatment.The prognosis of spine chondrosarcoma is usually poor, although most have low grade(Grade 1 or Grade 2). As a poor prognostic factor, compromised margins can beassociated to metastasis, especially to the lungs. In this case, the patientpresented metastasis to an unusual site, the skin.Persistent back pain should be investigated preferentially with a MRI orCT.Although rare, chondrosarcomas should be suspected in young adults presentingwith mass arising from the vertebral body with cortical disruption and ringand arc pattern of calcifications and foci of enhancement.CT and MRI are important to surgical planning in chondrosarcomas.MRI is better to delimitate the extension in vertebral bony tumors,particularly, the epidural component and the relation with the cauda equinaroots.


Malignant glioma, the most common malignant primary brain tumor in adults, usually occurs in supratentorial space as a single mass lesion, and cerebellar location and multiple appearance are uncommon. We report a case of a 69-year-old female with three lesions simultaneously found in the cerebellum on magnetic resonance images (MRIs) after suffering from gait disturbance. Two lesions were around 15 mm in size and the other one was observed as a spotty enhancement. Although MRI findings suggested brain metastases, whole body examinations denied any primary malignancies. Biopsy for one lesion in the cerebellum was performed, which resulted in pathological diagnosis of malignant astrocytoma. The lesions were considered multicentric glioma based on MRI definition. The treatment with temozolomide and whole brain radiation was completed. Although the patient was discharged in an independent state with the shrinkage of the tumors, she unexpectedly died following sudden loss of consciousness from an unknown cause one month after discharge. The coincidence of cerebellar location and multicentricity characterized by smallness is quite rare in glioma patients, and such MRI findings might be misleading for the diagnosis. We describe the details of the case and discuss the pathogenesis of this unique presentation of malignant glioma with the literatures. Glioma is the most common primary malignant brain tumor comprising approximately 30% of all primary brain tumors  and usuaIn this paper, we report a case of malignant glioma which presented with three lesions in the cerebellum. In particular, all lesions were small and considered multicentric based on MRI definition. The appearance of the lesions could be misleading for making diagnosis and treatment strategy. We describe the characteristics of the case and discuss the pathogenesis of the unique presentation, thereby providing some insights into multicentric glioma in the cerebellum.A 69-year-old woman, with a history of medication for hypertension, was referred to our hospital because of gait disturbance. Head MRI revealed three separate lesions in the cerebellum: the largest lesion of approximately 15 mm in diameter in the left cerebellum near the vermis with relatively regular enhancement , the lesWe suspected these lesions were metastatic tumors and performed thorough examination of whole body, which resulted in negative for any primary lesions. Because all lesions were small and debulking surgery was unnecessary, we decided to perform biopsy surgery targeting at the lesion near the vermis. We underwent needle biopsy under the guidance of navigation system, and postoperative course was uneventful. Histopathological examination revealed tumor cells with eosinophilic cytoplasm and pleomorphism, which were characterized by dense proliferation and diffuse infiltration in the granular cell layer of the cerebellum . NuclearFor molecular genetic characteristics, DNA was extracted from frozen tumor tissue. IDH gene was analyzed by direct sequencing, and allelic status of 1p/19q, EGFR, PDGFA, and PTEN was analyzed by multiplex ligation-dependent probe amplification (MLPA) method using SALSA MLPA kit P089 and P105 in accordance with the manufacturer's protocol  [The treatment with whole skull radiation (60 Gy) concomitant with temozolomide was administered and completed without any major side effects. Although the lesions were enlarged during the treatment Figures , the patIn this case, malignant glioma should be taken into account as a differential diagnosis because malignant gliomas can be multicentric and/or multifocal in the posterior fossa , 11. HowAlthough we successfully made the pathological diagnosis for this patient, the procedure for biopsy for this type of small lesions appeared more troublesome than usual and failure of sampling tumor tissue could happen. Therefore, the diagnosis as brain metastasis might be justified without pathology in such patients even in the situation with no known primary neoplasm, based on the facts that up to 15% of all patients with brain metastases have no clearly detected primary site  and thatThe mechanism of multiple gliomas has been an intriguing topic and some hypotheses are proposed for explaining the multicentricity of glioma . There mGenetically, the tumor had the amplification of EGFR and PDGFA, no loss of PTEN, and no mutation of IDH, which suggested primary glioblastoma based on the recent genetic investigations . The relCurrently, there are no clear guidelines regarding the optimal management of multiple glioma , and theWe presented the characteristics of a rare case of multicentric glioma in the cerebellum. This report could provide some supplemental suggestions for the differential diagnosis in the patients with small multiple lesions in the cerebellum. The elucidation of the pathogenesis of multiple glioma and the development of the optimal treatment strategy would be the important challenges in the future.


Intracranial epidermoid cysts are exceedingly rare lesions that result from a disorder of gastrulation. They are seen only in the pediatric patient population. We describe a 44-year-old Hispanic woman who presented with acute confusion. The family reported two months of progressive headaches and two weeks of fever, blurred central vision, and restricted visual fields. On examination, the patient appeared ill, with a low-grade fever and stiff neck. Neurological testing was limited but grossly non-focal. Computerized tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain showed a large cystic mass arising in the sella, where it displaced the normal pituitary gland. Cerebrospinal fluid (CSF) showed mildly elevated opening pressure with high protein, low glucose, and neutrophilic pleocytosis. Extensive serum and CSF evaluation were negative for infectious agents. The patient was initially started on empiric treatment for presumed infectious meningoencephalitis. As tests for bacterial and viral pathogens were normal, she was switched to fluconazole. The mental status returned to normal and she was discharged home with close follow up. She returned one month later with a recurrent headache, nausea, and stiff neck. The examination showed meningismus but was otherwise non-focal. MRI of the brain showed no change in the parasellar mass. Repeat CSF showed an even higher white blood cell (WBC) count and protein with continued hypo-glycorrhachia. She underwent trans-nasal trans-sphenoidal hypophysectomy and pathology revealed a squamous epithelium-lined keratin-filled cyst suggestive of an epidermoid cyst. The patient responded well to surgery and was discharged on pituitary hormone supplements alone. To our knowledge, this is a first adult case of recurrent chemical meningitis secondary to a ruptured epidermoid cyst in the sella. Meningitis is generally of infectious origin and occurs as a monophasic illness; it may be associated with a host of organisms. We present an unusual case of recurrent meningitis associated with a sellar-region epidermoid cyst, thought to be due to the intermittent release of toxic fluid contents. Central nervous system (CNS) epidermoid cysts are rare and only encountered in the pediatric population.A 44-year-old Hispanic woman presented with acute confusion. The family reported two months of progressive headaches and two weeks of fever, blurred central vision, and restricted visual fields. The review of systems was positive for recent nausea and vomiting. There was a remote history of treatment for latent tuberculosis and a recent history of a treated urinary tract infection. On examination, the patient appeared ill, with a low-grade fever (38.5°C) and stiff neck. She was somnolent and oriented only to self when aroused. Neurological testing was limited but grossly non-focal. A computerized tomography (CT) scan of the head and magnetic resonance imaging (MRI) of the brain showed a large cystic mass arising in the sella, where it displaced the normal pituitary gland. It extended over 1 cm above the tuberculum sella, compressing the optic chiasm  and protein 238) with continued hypo-glycorrhachia (26). She underwent an uncomplicated transnasal transsphenoidal surgery for the removal of the sellar lesion  abnormalities included high neutrophil-predominant WBC counts, moderately to markedly increased protein, and low glucose. These findings would usually suggest a bacterial, fungal or tuberculous infection, but an extensive search for these and other organisms was negative. Instead, biopsy showed evidence of a typical epidermoid (sebaceous) cyst. These cysts are thought to cause non-infectious meningeal inflammation through the release of their toxic internal fluid that may contain keratin and fatty acids. They are benign, slow-growing, and typically occur at the skull base  . They ocWe present a rare case of an adult with recurrent chemical meningitis secondary to a ruptured epidermoid cyst in the sella. Our patient presented with signs and symptoms of meningoencephalitis and was found to have evidence of chemical meningitis on contrast-enhancing sellar mass. Epidermoid cysts have been reported as rare tumors that occur in the pediatric patient population. The intra-sellar location of cysts has never been reported before. Epidermoid cysts are rare tumors that require a multidisciplinary approach including neurologists, radiologists, and surgeons. Early identification and intervention can result in an improved neurological outcome.


But when invasion occurred, the prognosis is poor.•Malignant IPMN with peritoneal dissemination also has poor prognosis.•CRS and HIPEC can prolong survival in malignant IPMN with peritoneal dissemination patient.•Pseudomyxoma peritonei can be found as rare manifestation of IPMN, that can associate with tumor rupture form diagnostic procedure like EUS-FNA or surgical procedure. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are treatment to deal with peritoneal dissemination that has excellent result for various cancer especially pseudomyxoma peritonei (PMP), mesothelioma. For now, this combination of treatment is still running for pancreatic adenocarcinoma but no description for pancreatic cystic tumor like malignant Intraductal papillary mucinous neoplasm (IPMN).We report 3 cases of malignant IPMN with peritoneal dissemination that treated with CRS and HIPEC. Two cases have atypical presentation of malignant IPMN with PMP. HIPEC was performed using cisplatin-based regimen. The longest survival in this study is 93 months, compared to the median survival of 44.3 months without HIPEC.CRS and HIPEC have not proven to treat in patient with pancreatic cystic tumor with peritoneal dissemination. But these treatments can be improved survival outcome in selected patient.CRS and HIPEC trend to improve survival. More studies need, not only to evaluate the role of HIPEC on malignant IPMN, but also prognosis and outcome. CRS and HIPEC has proved its benefit on Pseudomyxoma peritonei (PMP), mesothelioma, gastrointestinal tract cancer, and ovarian cancer. PMP, the presence of mucin in peritoneal cavity, originated from IPMN is rare condition, that was introduced by Zanelli et al. in 1998 .We found peritoneal dissemination from malignant IPMN 3 cases in past 10 years. All cases underwent CRS and HIPEC under the same concept of other cancers.2We reviewed medical records from 2008 to 2018, there were 3 cases of malignant IPMN with peritoneal dissemination. We have consent for the publication all three patients and accompanying images. The procedure-specific consent, patient data and material of this study had reviewed and approved by our institutional review board with ethic number H19, 2008. All patients underwent the same standard CRS procedure by surgical oncologist. HIPEC was discussed with patient and decided before procedure but if intraoperative bleeding more than 4000 ml, HIPEC will not performed. This work has been reported in line with the SCARE criteria. [33.1A 69-year-old man presented with chronic pancreatitis. Computer Tomography (CT) showed cystic lesion at tail of pancreas 10 cm with mucinous ascites and scallop edge of liver and spleen. The appendix was unremarkable. Exploratory laparotomy was performed and found mucinous ascites without malignant cell. Large cystic mass at tail of pancreas with enlarged 10 mm. Cystic disruption was detected. Complete CRS was performed. Immediately after resection, HIPEC was administered with cisplatin (CDDP) 100 mg and mitomycin C (MMC) 20 mg in 42 °C condition for 60 min. Histology showed mucinous carcinoma on top of IPMN, MPD margin was not free from tumor but no lymphatic or perineural involvement was seen. Mucinous tumor was invaded to submucosa layer of stomach, right colon and to splenic parenchyma. No recurrence disease found during follow up period.After 6 years of surgery, he had intestinal obstruction from recurrent tumor at pancreatic stump around previous ileo-colostomy anastomosis. Second operation was performed but tumors at subhepatic area and heptoduodenal ligament were intentionally left untouched due to thick adhesion. Completeness of cytoreduction (CCR) score was 3. HIPEC was repeated using oxaliplatin (L-OHP) 100 mg and 5-fluorouracil (5-FU) under hyperthermic condition (42 °C) for 60 min. Pathological report showed recurrent of pancreatic mucinous cancer. Unfortunately, 3 months after second operation, tumor was increased in size around hepatic hilum and pancreatic stump. Percutaneous transhepatic biliary drainage was performed to relief jaundice followed by proton beam radiation 52 Gy for 26 times. Complete response was achieved but he passed away from tumor complication. He survived for 93 months after initial diagnosis of malignant IPMN.3.2A previously healthy 54-year-old man was noted of having high CA 19-9 on screening program. CT abdomen showed 5 cm cystic lesion at tail of pancreas. EUS found multiple cystic lesions connect to 1.1 cm MPD and mural nodule. Malignant IPMN was diagnosed. Distal pancreatectomy was performed. Pathological study revealed malignant IPMN without lymphatic involvement, free resection margin and no residual tumor found. After operation oral S1 was stated as an adjuvant treatment for 6 courses. 6 months after operation, CA19-9 was increased. CT showed left lower abdominal mass 3 cm suspected of peritoneal metastasis. S1 100 mg per day was started again and continued for 28 days. He underwent laparotomy 4 weeks after chemotherapy (CMT). Intraoperative finding showed no ascites, but fluid washing was positive for malignant cell. PCI score was 4. Macroscopic tumor was completely resected with extended right colectomy, omentectomy and peritonectomy. Metastatic carcinoma from malignant IPMN was confirmed. Adjuvant CMT was given.9 months after second operation, recurrent mass on the left abdominal wall was found. Re-exploratory laparotomy with CRS was performed and achieved CCR 0. HIPEC was administrated with MMC 20 mg and CDDP 40 mg at 42 °C for 40 min. Adjuvant CMT with irinotecan (CPT-11) and S1 was started. Now he survives well with chemotherapy session no evidence of disease recurrent on CT images  during m3.3A male, 69 years old with underlying of diabetes mellitus, hypertension and glaucoma. He came to the hospital with severe epigastric pain for 3 months which was spontaneously disappeared. Abdominal ultrasonography was periodically performed and revealed pancreatic cystic lesion at tail of pancreas size 3.1 cm in diameter. MPD was dilated 10 mm in diameter. No ascites, evidence of cystic disruption, mural nodule nor enhanced lesion was found in the subsequent EUS. 6 months later pancreatic cyst was increased in size to 6 cm, with disruption of pancreatic cyst and spreading of mucinous content in abdomen causing scallop edge of liver and spleen . The dia4IPMN is not a common disease but with recent increased in awareness. Many imaging modalities were introduced to improve lesion detection and differentiation of invasive foci. Prevalence of cancer in IPMN was 6–92% . SurgicaPMP, in literature reviewed, mostly associated with mucocele of appendix or ovarian mucinous tumor. PMP associated with pancreatic tumor was introduced by Zanelli et al. in 1998 . Our stuSeveral treatment modalities have been utilized in management of peritoneal dissemination. Modern treatments such as peritonectomy and HIPEC, which were purposed by Sugarbaker PH , have beOne case in this series had experienced intraoperative massive bleeding which is one of contraindication of HIPEC because hyperthermic condition will lead to vasodilatation and allow more bleeding from raw surface.Recurrence rate of malignant IPMN was approximately 33.8% with median survival of 46 months . On the 5However, CRS and HIPEC are not yet approved for the treatment of pancreatic cancer. For malignant IPMN with peritoneal dissemination CRS and HIPEC can be successfully treated in selected case and trend to prolong survival outcome. Further studies are still needed to prove the real benefit of HIPEC on pancreatic cystic tumor.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The procedure-specific consent, patient data and material of this study had reviewed and approved by the ethical review bodies of Kishiwada Tokushokai hospital with ethic number H19, 2008.We confirmed that we have consent for the publication of this case series for all three patients and accompanying images.Substantial contributions to conception and design by Y. Yonemura and C. Sirisai.Acquisition of data by Y. Yonemura, H. Ishibahi, S. Wakama, A. Mizumoto.Drafting the article by C. Sirisai.Critical revision of manuscript for intellectual content by Y. Yonemura, A. Mizumoto.All members have been approved the final version to be published.This study had been approved for registration at TCTR. The identification number is TCTR20190704001.Prof. Yutaka Yonemura.Dr. Chayanit Sirisai.Not commissioned, externally peer-reviewed.All authors declare no conflict of interest of any financial and personal relationship.


Epiploic appendagitis is a relatively rare disease characterized by an inflammation of fat-filled serosal outpouchings of the large intestine, called epiploic appendices. Diagnosis of epiploic appendagitis is made challenging by the lack of pathognomonic clinical features and should therefore be considered as a potential diagnosis by exclusion first of all with appendicitis or diverticulitis which are the most important causes of lower abdominal pain. Currently, with the increasing use of ultrasound and computed tomography in the evaluation of acute abdominal pain, epiploic appendagitis can be diagnosed by characteristic diagnostic imaging features. We present a case of epiploic appendagitis with objective of increasing knowledge of this disease and its diagnostic imaging findings, in order to reduce harmful and unnecessary surgical interventions. Epiploic appendagitis, also known as appendicitis epiploica, hemorrhagic epiploitis, epiplopericolitis, or appendagitis –3, is a μl , with neutrophilia  and fibrinogen of 839 mg/dL (160-350). Chest X-ray showed no lung consolidation, effusion, collapse, or air under the diaphragm. Abdominal X-ray was performed showing a poor representation of small and large bowel meteorism with no associated pathological air-fluid levels, as from spastic reflex ileus (A 45-year-old Caucasian man presented to our emergency department (ED) with acute pain in the left iliac fossa that started the day before presentation. At clinical examination VAS  score was 7/10. He had fever and nausea and denied any associated chills, trauma to the area, vomiting, dysuria, haematuria, change in bowel habits, loss of weight, or skin rash. He also denied any history of renal colic. His family history was positive for gallbladder diseases requiring cholecystectomy; surgical history was negative and no chronic diseases were reported. At physical examination the patient showed tenderness and pain in the left iliac fossa associated with abdominal guarding, suggestive for diverticulitis. There was no pulsatile or palpable mass or costovertebral angle tenderness. Physical examination was otherwise unremarkable. The patient was placed on observation status and laboratory and diagnostic tests were ordered. The patient was treated with an intravenous (IV) bolus of 250 mL of normal saline solution followed by 125 mL/h IV normal saline solution and Ketorolac trometamina  30 mg IV for pain control. Laboratory results showed White Blood Cell (WBC) count of 12,10 x 1000/ex ileus . An evalex ileus . Accordiex ileus . There wEpiploic appendagitis is a rare condition with an incidence of 8.8 per 1 million people and it is usually a diagnosis by exclusion . EpiploiCurrently, thanks to the increased use of US and CT in the evaluation of acute abdominal pain, most cases of epiploic appendagitis are diagnosed using CT (preferred) and US scan , 21. InsMR may show a small oval mass with a signal intensity similar to the fat. Contrast-enhanced T1-weighted MRI images show also an enhancing rim around the oval fatty mass . The wall of the colon may show associated reactive thickening .Chronically, a calcification can develop within the infarcted appendage epiploica and may detach to form an intraperitoneal loose body  . Rarely,Colonoscopy is sometimes performed before CT or US for the evaluation of abdominal colic pain; however, such a procedure will not provide an explanation for the presented symptoms in patients who have epiploic appendagitis . In our Differential diagnosis for the imaging features of acute epiploic appendagitis include other acute inflammatory diseases, such as acute appendicitis, acute diverticulitis and sclerosing mesenteritis, fat-containing primary tumors or metastasis, and acute omental infarction, each one with characteristics imaging findings . In partIn the current literature, epiploic appendagitis is predominantly described as a self-limiting disorder and most patients are treated conservatively and nonsurgically either with or without nonsteroidal anti-inflammatory drugs as our case .Unlike its mimics, such as appendicitis or diverticulitis, epiploic appendagitis is, generally, a self-limiting disease and is treated with anti-inflammatory therapy , 16, 20.


Acute otitis media is one of the most common infectious diseases in the paediatric age and although its complications such as acute mastoiditis have become rare thanks to improvements in therapeutic approaches, possible serious complications such as septic arthritis of the temporomandibular joint may develop. A prompt diagnosis and adequate treatment are essential to achieving the best outcome and avoiding serious sequelae. We describe a case occurring in a previously healthy 6-year-old female and review the literature currently available on this topic.The patient presented a right temporomandibular septic arthritis with initial mandibular bone involvement secondary to acute otitis media. She presented with torcicollis, trismus, right preauricular swelling over the temporomandibular joint and was successfully treated with antibiotic treatment alone.Septic arthritis of the temporomandibular joint is a rare complication of acute otitis media or acute mastoiditis in children. It should be suspected in patients presenting with trismus, preauricular swelling or fever. No guidelines on the diagnosis and treatment of this infectious disease are currently available. More than 80% of children under 3 years of age experiences at least one episode of acute otitis media (AOM) and about one third of children has a recurrence by the age of 3 years, making AOM one of the most common paediatric infectious disease , 2. MoreOther severe complications include subperiosteal abscess, facial paralysis, serous and suppurative labyrinthitis, sigmoid sinus thrombosis, epidural or intracerebral abscess, meningitis, petrous apicitis, and otitic hydrocephalus. Fortunately, modern treatment options make these complications rare in developed countries .Septic arthritis of the temporomandibular joint (TMJ) is a rare complication of AOM with or without otomastoiditis in children; however, a prompt diagnosis and appropriate treatment are crucial to reducing the risk of complications such as TMJ ankylosis and achieving the best outcome . There aHere we report the case of a previously healthy child with right TMJ septic arthritis secondary to AOM. We also review literature reports of otogenic cases of TMJ septic arthritis in children, published in English since 2000, in order to discuss the main clinical findings and the diagnostic and therapeutic strategies for this condition.3 with neutrophil predominance and elevated C-reactive protein (CRP) of 8.1 mg/dL . A blood culture was also performed but resulted negative. On the basis of these findings, broad spectrum intravenous antibiotic treatment with ceftriaxone (75 mg/kg/day) was introduced, but 3 days later it was replaced with a combination of piperacillin-tazobactam (100 mg/kg/day) and vancomycin (40 mg/kg/day) due to minimal clinical improvement. This antibiotic regimen was well tolerated by the patient and it was continued for a total of 4 weeks with a gradual resolution of the symptoms and normalisation of the white blood cell count and CRP. The patient was discharged in good general conditions under an oral antibiotic treatment with clindamycin (20 mg/kg/day) for 2 weeks. The MRI of the head and neck performed 1 month later revealed a further improvement in joint effusion and a reduction in bone involvement  for 2 days without improvement. There was no history of trauma. On admission, the child was in good general conditions and presented with torcicollis, trismus, right preauricular swelling over the temporomandibular joint. On otoscopy right tympanic hyperemia with the evidence of middle ear fluid consistent with AOM was observed. Significant pain on chewing and right-sided cervical lymphadenopathy were also reported. She was apyretic and the rest of her clinical examination was normal. An ultrasound scan revealed a fluid collection of 4 mm in size in the right TMJ. A contrast-enhanced computed tomography (CT) scan of the head and neck confirmed the presence of effusion in the right TMJ, consistent with the diagnosis of septic arthritis, with surrounding lymphadenopathy and initial signs of bone rarefaction of the right mandibular condyle. An opacity of the right mastoid was detected radiologically, but there were no clinical signs of mastoiditis. These findings were also confirmed by the subsequent magnetic resonance imaging (MRI) of the head and neck Fig. a. On admSeptic arthritis of TMJ is a rare complication of AOM with or without otomastoiditis in children. We identified 34 cases of paediatric TMJ septic arthritis published since 2000 –14. Of tThe clinical presentations of TMJ septic arthritis include fever, trismus, preauricular swelling, and TMJ tenderness .In our case, there was no history of fever, but the other main clinical signs were all present.Although a diagnosis of TMJ septic arthritis can be suspected on the basis of clinical findings, radiological confirmation is essential in order to identify other possible complications. Contrast-enhanced CT is the most frequent imaging technique used in the assessment of TMJ , 10–13. In the case described by Bast et al., MRI was used for diagnosis, whereas Amos et al., in emergent evaluation settings, based their diagnosis on orthopantomography and ultrasound scans , 9.In our case, the ultrasound scan revealed the presence of a fluid collection in the right TMJ, but the CT scan of the head and neck was essential to describing the initial bone involvement. MRI was useful for monitoring the radiological evolution of the condition and preventing our patient from being exposed to radiation.Streptococcus. In one case, it was associated with Staphylococcus epidermidis. In the retrospective study conducted by Burgess et al., of 9 children with TMJ septic arthritis only 3 had an identified causative organism and it was Fusobacterium necrophorum [Laboratory findings often reveal an increase in the white blood cell count and CRP but their specificity and sensitivity are too poor to allow diagnosis without further clinical and radiological data . The mosrophorum . It is irophorum , 12.No guidelines on the treatment of TMJ septic arthritis are currently available. Broad spectrum intravenous antibiotic treatment is essential and can be modified on the basis of the antibiograms obtained from the cultural investigations . The durAlongside antibiotics, surgery plays a key role in the treatment of septic arthritis in children . DiffereCurrently, there is no specific data on mandibular physiotherapy; however, different reports have suggested that it could be useful in order to improve condyle excursion and prevent fibrotic adhesions. Active opening and bite exercises in particular could improve maximal incisal opening .To conclude, septic arthritis of the TMJ is a rare but potentially severe complication of AOM or otomastoiditis in children. It should be suspected in the presence of trismus, jaw pain and preauricular swelling, in order to perform radiological examinations to confirm the diagnosis and to initiate adequate antibiotic and, if necessary, surgical treatment. A prompt diagnosis and adequate treatment are essential if severe complications as destruction of the synovial tissues, fibrotic adhesions and joint ankylosis are to be avoided .


Duodenal duplication is an extremely rare congenital abnormality that occurs mostly in children. It represents only 2% to 12% of all gastrointestinal tract duplication. Its clinical presentation is highly variable and non-specific making the positive diagnosis very difficult. Imaging modalities can help to detect the lesions making the diagnosis more accurate before surgery. Here, we report a case of duodenal duplication revealed by chronic abdominal pain and treated by surgical resection in a 26-year-old man. Even in adults, it is necessary to evoke the diagnosis of duodenal duplication in patients with unexplained abdominal pain. Surgical resection remains the treatment of choice and endoscopic treatment is reserved for selected patients in whom surgery is difficult. Duodenal duplication (DD) is a rare congenital malformation that occurs oftenly in early childhood, but could also be discovered at any period of life. The diagnosis remains difficult and can be challenging . The manA 26-year-old man presented with recurrent epigastric pain evolving since three months associated with intermittent jaundice and fever. There was no history of vomiting, anorexia or change in bowel habits. Physical examination was normal and laboratory values were normal. A Computed tomography (CT) of the abdomen revealed the presence of 3.5×3 cm cystic mass within the second portion of the duodenum near the head of the pancreas without pancreaticobiliairy ductal dilatation. Endoscopic ultrasonography showed a double layered wall of the second part of the duodenum with a cystic lesion. Magnetic resonance cholangiopancreatography (MRCP) revealed that the cyst was confined to the duodenum and did not involve the intra-pancreatic portion of the common bile duct. These appearances are consistent with the diagnosis of a DD. The patient underwent an open abdominal exploration by laparotomy. A limited duodenotomy was performed on the anterior surface of the second portion of the duodenum. We found three-cm spherical structure adjoined to the duodenal wall just near the biliopancreatic ampulla . These fet al defined three criteria for the diagnosis, including the presence of an intimate attachment to the native gastrointestinal tract, a muscle coat and alimentary mucosal lining [Fitz gave the first description of a DD in 1884 . DD in al lining . DD can l lining . Clinical lining . Imagingl lining . It has DD is a relatively rare congenital anomaly that may occur anywhere along the gastro-intestinal tract. It is necessary to evoke this diagnosis in front of unexplained abdominal pain. Endoscopic approach is possible but requires operative endoscopic skills.The authors declare no competing interests.


Duodenal diverticulum is a rare disease that can be easily missed. The incidence of duodenal diverticulum diagnosed by upper GI study is approximately 5%. Autopsy results show that 22% of the population have duodenum diverticulum. Most patients with duodenal diverticulum are asymptomatic. However, complications like inflammation, perforation with retroperitoneal abscess, sepsis, pancreatitis, bile duct obstruction, and bleeding can occur. Approximately 162 cases of perforated duodenal diverticulum have been reported in the literature.  We present a rare case of an 82-year-old female with perforation of a duodenal diverticulum caused by small bowel obstruction; in addition to this, there was a synchronous colonic tumor.  Diagnosis and management of this rare disorder are controversial. Nonoperative management is advocated in some cases. Some of the cases require early aggressive surgical intervention. The mortality rate remains approximately 45% in all these patients. Perforation of the duodenum diverticulum (DD) is a rare disease that can be easily missed as it can be a clinical diagnosis. Management of the perforation requires urgent surgical intervention for favorable outcomes. Perforation can be caused by infections such as diverticulitis, ulceration, foreign body, trauma, and iatrogenic perforation after ERCP and would require CT scan of the abdomen for diagnosis and treatment in some cases, while diagnosis of duodenal diverticulum can be made with upper gastrointestinal series.An 82-year-old African American female with history of hypertension, chronic active smoker for 60 years along with prior surgical history significant for a laparotomy more than 20 years previously for unknown reason who was initially admitted to the medical service after a fall. She had a long history of nonspecific lower abdominal pain. As per her family, she had not seen a doctor for 10 years and never had a colonoscopy. She reported unintentional weight loss. Vital signs at the time of presentation were stable. On physical examination, she appeared cachectic and dehydrated. Her abdomen was soft, non-tender with audible bowel sounds. Mild right lower quadrant tenderness was noted. Labs were significant for microcytic hypochromic anemia and urine analysis positive for leukocyte esterase. Liver function test was normal. Chest X-ray showed cardiomegaly. Abdominal US revealed mild ascites and dilated common bile duct to 1 cm. The patient was admitted to medical service with a diagnosis of dehydration, failure to thrive, and for work-up of an occult gastrointestinal malignancy. She was scheduled for EGD and colonoscopy by gastroenterology team. In addition to all of this, her CEA was 12.2 ng/ml . While the patient was on the medical service, her hemoglobin dropped to 6.2 gm/dL requiring blood transfusions. During the second unit of blood transfusion, the patient became hypoxemic and tachypneic. She was transferred to Medical Intensive Care Unit (MICU) and subsequently intubated for acute respiratory failure. Chest X-ray at this point showed bilateral infiltrates, and the patient was started on IV antibiotics for possible pneumonia. The scheduled GI procedures were cancelled due to critical health status. She had echocardiography in MICU which revealed mitral stenosis and severe pulmonary hypertension, with normal ejection fraction. Her respiratory status improved, and she was transferred back to medical floor after staying four days in MICU. She also had urine culture which grew klebsiella. Three days later after being transferred from MICU, she developed abdominal distension. A CT scan of the abdomen without contrast was obtained which revealed gastric, small bowel, and colonic distension. There was copious amount of stool in the colon. She was transferred to the surgical service for management of possible ileus/stool impaction pending colonoscopy to rule out colonic lesion. She was managed with nil per os, nasogastric tube suction, intravenous fluid hydration, and enemas. Nasogastric tube output was minimal but the patient's abdomen remained distended while on surgical service. The patient became hypotensive and tachycardic and less responsive. After fluid resuscitation, another CT of the chest and abdomen with oral and intravenous contrast was performed one week from prior CT, which revealed persistent dilation of the stomach, small bowel, and large bowel, a left colonic mass, and large amount of retroperitoneal free fluid in the region of the duodenum and pancreas Figures . The thiDuodenal diverticulum complications are rarely seen, and it is the second most common site of diverticula of the gastrointestinal tract after the colon . DD can Many operative techniques have been described. After adequate mobilization of the duodenum, the diverticulum should be dissected completely down to the base and either handsewn or stapled diverticulectomy can be performed. The defect can be closed in layers . The relIf the perforated duodenal diverticulum is in the fourth portion of the duodenum, partial duodenectomy can be performed and reconstruction with end-to-side doudenojejunostomy .In the presence of significant inflammation, more complex procedures have been described. A Roux-en-Y loop of the jejunum is brought through a rent in the transverse mesocolon, the duodenum is transected, and the duodenal stump is oversewn. The Roux limb of the jejunum was anastomosed end to end to the duodenum. A jejunojejunostomy is created 40 cm distal to the duodenojejunostomy. A drain should be placed. As an alternative, vagotomy, antrectomy closure of duodenal stump, and Billroth 2 reconstruction can be performed. This decreases the risk of duodenal fistula . For larDuodenal diverticular perforation can be challenging as it is a rare disease and difficult to diagnose. Nonoperative management is only in selected patient's population. CT scan can help diagnose the perforation and require urgent surgical intervention.


Pancreatitis in both acute and chronic variants is a common health concern in the US as well as globally. While the most common etiologies for disease remain gallstone impaction in the common bile duct and alcohol abuse, recent studies have shown that genetics may play a significant role as well. Unfortunately, this correlation is not clearly defined and at present, we lack the ability to identify which patients with known pancreatic genetic polymorphisms will develop pancreatitis. We describe the case of a middle-aged male who presented with recurrent pancreatitis in the setting of the serine peptidase inhibitor, Kazal type 1 (SPINK-1) genetic polymorphism. Additionally, we discuss the mechanism behind SPINK-1 polymorphisms in the development of pancreatitis as well as the role of genetic screening for the polymorphism in the general population. With the annual incidence of acute pancreatitis in the United States ranging from 4.9 to 35 per 100,000 persons, the condition remains a very common and costly healthcare concern . StudiesA 56-year-old male with a past medical history significant for chronic pancreatitis with heterogeneous SPINK-1 mutation (tested for at age 27 due to recurrent episodes of acute pancreatitis) presented with severe left lower quadrant (LLQ) abdominal pain. The patient had already experienced seven episodes of acute pancreatitis within the past year alone, with his last hospitalization for the issue roughly one month prior to current admission. The patient had a remote alcohol and smoking history though he denied any use within the past 20 years, and he recently became a vegan in an attempt to reduce his risk for recurrent acute episodes of pancreatitis. On admission, the patient’s vitals were within normal limits and physical exam was significant only for severe LLQ tenderness and hypoactive bowel sounds. Labs revealed an aspartate aminotransferase of 14 U/L, alanine transferase of 12 U/L, alkaline phosphatase of 63 U/L, lipase 43 U/L, total cholesterol 138 mg/dL, triglycerides of 129 mg/dL, and an international normalized ratio of 1.4. Computed tomography (CT) of the abdomen and pelvis with contrast revealed an enlarging known cystic body in the pancreatic tail measuring 3.4 x 5.3 cm. Peripancreatic inflammatory changes were identified surrounding the distal body of the pancreas and extending along the spleen representing a pseudocyst , chymotrypsin C alleles (CTRC), and protein coding serine protease 1 (PRSS1). SPINK-1 polymorphisms are rare and seen in only approximately 2% of the US population. The polymorphism has been attributed to 5-6% of all chronic pancreatitis cases and 15-40% of idiopathic pancreatitis cases [While many of the extrinsic etiologies for acute and chronic pancreatitis are known, genetic components should not be excluded, especially in those presenting with acute episodes at younger ages (20’s vs. 30’s) or recurrent episodes after appropriate lifestyle modifications. Genetic components of pancreatitis are at this time not well understood as there does not appear to be a concrete correlation between polymorphism and the development of pancreatitis. Genetic polymorphisms such as the SPINK-1 mutation serve as a disease risk modifier rather than a directly attributable cause of pancreatitis. While early identification of genetic polymorphisms may help with pancreatitis risk stratification, the as of yet unidentified direct correlation between SPINK-1 mutation and pancreatitis development has led guidelines to recommend against routine childhood screening for the mutation.


Purpose: To report a rare case of non-tuberculous mycobacterial (NTM) choroiditis masquerading as choroidal tumour, where the initial diagnosis was masked by keratitis. Casedescription: A 57-year-old heroin chaser with a pre-existing left eye blindness due to past blunt trauma presented with diffuse bacterial keratitis on the same side. Systemic examination revealed multiple non-tender cervical lymphadenopathies. B-scan ultrasonography showed a hyperechoic choroidal mass with surrounding exudative retinal detachment, resembling a choroidal tumour. However, computed tomography (CT) and magnetic resonance imaging (MRI) scan findings were suggestive of inflammatory choroidal changes. Inflammatory markers were significantly raised and infective screening was positive for HIV and Hepatitis C. Tuberculosis workup was normal. In view of intractable pain, evisceration was done and his vitreous humour was sent for polymerase chain reaction (PCR). It was reported to be positive for Mycobacterium Fortuitum. Conclusion: NTM ocular infections are rare, challenging to diagnose, and potentially sight threatening. Early recognition and prompt treatment is life and vision saving. Non-tuberculous mycobacteria (NTM) are ubiquitous organisms most commonly found in soil, water, air, and food. Although NTM ocular infections are rare, there has been a steady increase of such cases in the past two decades . Risk faM. Fortuitum is usually associated with indolent keratitis and low grade ocular inflammation. The first case was reported in 1965 where M. Fortuitum caused chronic keratitis following corneal foreign body removal . After tA 57-year-old man, who has been blind in the left eye secondary to blunt trauma for the past ten years, presented with a three-day history of left eye pain associated with purulent discharge after a foreign body entry. The patient had no known medical illness and he was a heroin chaser. On examination, he had no light perception in the left eye with positive relative afferent pupillary light defect. There was a melting central corneal ulcer, associated with proptosis, periorbital swelling, diffuse conjunctival chemosis, and injection Figure 1 . His intDue to the patient’s immunocompromised status, markedly elevated ESR, lymphadenopathy, and inflammatory changes of the mass, a possible diagnosis of intraocular tuberculosis (TB) was made. However, TB work-up, which included chest X-ray, Mantoux test and sputum to look for acid-fast bacilli were normal. The patient was started on Ceftazidime 5% and fortified Gentamicin 0.9% eye drops which was sensitive for the Pseudomonas Aeruginosa species and two IOP lowering agents. Despite the initial targeted treatment, the patient’s condition worsened. His cornea perforated within two days of presentation and the patient was in intractable pain, not responding to analgesics. After an elaborated discussion and counselling, we proceeded with evisceration of the affected eye. The corneal tissue and vitreous humour was sent for TB polymerase chain reaction (PCR). The PCR result came back positive for M. Fortuitum. The patient was not started on any systemic antibiotics as there was no evidence of systemic dissemination of the infection.This case illustrates that NTM keratitis and choroiditis are rare opportunistic infections that can pose both diagnostic and therapeutic challenges. In the literature, the average duration from onset of symptoms to diagnosis is 10 weeks . In thisThe B-mode ultrasonography features of this patient mimicked a choroidal tumour with collar stud appearance with low internal reflectivity. Similar to our case, Lai et al. from Japan reported a case of NTM choroiditis in a HIV patient which was mistaken for ocular lymphoma . All theThe three commonest NTM species, M. Chelonae, M. Fortuitum and M. Abscessus are part of Group IV NTM, which are also known as rapidly growing NTM. These organisms take 7–10 days to culture, unlike other groups of NTM, which take up to 2–4 weeks . Based oIntraocular NTM infections were reported to have poorer response to medical treatment as compared periocular, adnexal, and ocular surface NTM infections. Studies have shown that Amikacin and Clarithromycin were more efficacious, while fluoroquinolones in general were less effective , 9]. Co. Co9]. CNTM ocular infections are rare and pose diagnostic challenges. A delay in diagnosis leads to severe morbidity and poor visual outcome. Hence, high index of suspicion, prompt investigation and treatment could be sight saving. Therapeutic surgical intervention may be necessary to control the infection.The authors declare that they have no competing interests.Written consent to publish the case report was obtained. Radiology Department of Hospital Tuanku Ampuan Najihah, Kuala Pilah for interpretation of relevant imaging


Necrosis developing 4 weeks after the initial acute pancreatitis attack is known as walled-off pancreatic necrosis (WOPN). Complications of WOPN include spontaneous rupture into the peritoneal cavity or hollow viscus obstruction by compression of surrounding structures, including the colon, stomach, duodenum, and common bile duct. There have also been cases of pseudocyst rupture into blood vessels. This case report is unique in that it highlights a patient with inferior vena cava compression leading to hemodynamic instability due to the mass effect of WOPN and has not been previously reported. Most uncomplicated acute pancreatic fluid collections are managed conservatively unless symptomatic or infected.2 In these more severe cases, minimally invasive approaches, including endoscopic drainage of WOPN, should be considered. Complications of WOPN include spontaneous rupture into the peritoneal cavity or hollow viscus obstruction by compression of surrounding structures, including the colon, stomach, duodenum, and common bile duct.3 There have also been cases of pseudocyst rupture into blood vessels.4 This case is unique in that it highlights a patient who developed hemodynamic instability from inferior vena cava (IVC) compression secondary to mass effect from WOPN, necessitating further intervention.Severe acute pancreatitis associated with necrosis leads to significant morbidity and mortality.A 56-year-old man with a history of alcoholism presented to a local hospital for right lower quadrant abdominal pain and elevated serum amylase. His lipase level was 1,130 U/L. No jaundice or signs of ascending cholangitis were identified. The initial computed tomography (CT) scan with intravenous contrast showed moderate amounts of pancreatic necrosis, mainly on the right side of the abdomen. To delineate the integrity of the pancreatic duct, magnetic resonance cholangiopancreatography was performed. Magnetic resonance cholangiopancreatography showed a dilated main pancreatic duct proximally toward the head and neck of the pancreas with tapering distally toward the body and tail and a hypointense filling defect in the distal main pancreatic duct just before the insertion into the ampulla.The patient was treated conservatively for acute necrotizing pancreatitis (ANP), but his abdominal pain did not improve significantly over the subsequent 10 days. A repeat CT scan was performed, which revealed increasing amounts of retroperitoneal fluid mainly to the right of the midline involving the right perinephric and retronephric spaces, causing displacement of the right kidney and poor delineation of the IVC secondary to a mass effect (Figure Over the next 2 weeks, the patient developed progressive abdominal distention, followed by sudden-onset shortness of breath, and he became hemodynamically unstable. The patient was transferred to the intensive care unit, and another CT scan was performed which showed massive WOPN, IVC collapse, and a right hydroureter. An emergent CT-guided percutaneous drainage was performed, which resulted in improvement of the respiratory distress and hemodynamics over the next 48 hours. The patient was determined to have hemodynamic instability secondary to impaired venous return and respiratory distress secondary to decreased total lung capacity, leading to compressive atelectasis, both of which markedly improved as the fluid was drained. The patient was then discharged 3 days later to a long-term acute care facility.1 The term WOPN was first used by Connor et al in 2005 and was subsequently officially established in 2006 by the American Gastroenterological Association.3 Pancreatitis with an unexpectedly long course, unresponsiveness to medical therapy, hemodynamic instability, and fluid on CT indicate the possibility of necrosis and later WOPN development. Medical treatment is generally supportive, and antibiotics such as imipenem can be administered to patients with bacteremia. The ultimate treatment of choice for WOPN, however, would consist of drainage to avoid increased morbidity and mortality.The incidence of pancreatitis in the United States is approximately 185,000 cases per year. ANP is reported to occur in approximately 20% of all episodes of pancreatitis. WOPN, formerly known as a pancreatic abscess, is a late complication of severe acute pancreatitis, occurring 4 weeks after the episode in 1-9% of cases.1 Severe complications of WOPN include fistula formation, recurrent pancreatitis, rupture into the peritoneal cavity, and hollow viscus obstruction by compression of surrounding structures, including the colon, stomach, duodenum and common bile duct.3 If left untreated, WOPN can progress to sepsis and death.ANP, depending on the degree of necrosis and surgical debridement, can have great implications on the morbidity of the patient, including insufficient endocrine and exocrine functioning of the pancreas to significantly affect the patient's quality of life.4 Although cases of IVC thrombosis in necrotizing pancreatitis have been seen, no cases of WOPN directly compressing the IVC and leading to hemodynamic instability have been reported. This emphasizes the rarity of this complication and the critical role of imaging and decompression to relieve the mass effect before progression to hemodynamic instability and shock.An important consideration in WOPN is vascular complications. There have been cases of pseudocyst rupture into blood vessels, including the portal vein, leading to thrombosis and subsequent lysis of the thrombus by pancreatic enzymes. Communication of the pseudocyst and portal venous system can be seen on imaging. Similarly, a case report by Ramachandran et al reported a case of WOPN rupturing into the IVC leading to its thrombosis.Sepsis is the primary concern in patients presenting with hypotension and history of WOPN. This case highlights that, although rare, impaired venous return secondary to a mass effect due to a large pancreatic collection should be considered in the differential diagnosis for all patients with a history of recent pancreatitis presenting with shock. In addition, this case demonstrates that early endoscopic or CT-guided drainage may be of benefit in select cases of massive pancreatic fluid collections in a small subgroup of patients who have radiologic evidence of compression of vascular structures or vital organs before symptoms of clinical deterioration develop. Early detection and intervention measures should be taken in cases of WOPN to decrease mortality and morbidity from this disease and its complications.Author contributions: All the authors contributed equally to this manuscript. T. Goyal is the article guarantor.Financial disclosure: None to report.Informed consent was obtained for this case report.Previous presentation: This case was presented at the American College of Gastroenterology Annual Scientific Meeting; October 16–21 2015; Honolulu, Hawaii.


Tubulo-villous adenoma is a rare benign appendiceal neoplasm often asymptomatic with the most clinical manifestation that resembles acute appendicitis. Pre-operative diagnosis is difficult by its rarity and the absence of typical symptoms. Adequate treatment is surgical resection.th post-operative day.A 69-year-old male was admitted to the Emergency Department with a two-day history of abdominal pain associated with constipation. Abdominal examination revealed abdominal pain localized, at deep palpation, in the right iliac fossa and in hypogastrium without obvious muscle guarding or rebound tenderness. Laboratory tests showed a normal white blood cell count with 82.3% neutrophils and high C-reactive protein level. After a negative abdominal ecography, the patient was evaluated by abdominal computed tomography, which revealed acute appendicitis. The patient was submitted to surgery and open appendectomy was performed. The post-operative course was uneventful and the patient was discharged on the 5Acute appendicitis may be a clinical manifestation of a benign appendiceal neoplasm. Pre-operative radiological investigations not always are useful for an early diagnosis that is mandatory because of the potential risk of malignant degeneration. Appropriate treatment of acute appendicitis is debated: some surgeons suggest operative treatment, but others advocate for non-operative management. In our case the patient was submitted to surgery avoiding the risk of diagnostic delay of neoplasm.Appendiceal tubulo-villous adenoma is a rare neoplasm difficult to diagnose and suspect because of lack of pathognomonic symptoms and specific diagnostic signs. Acute appendicitis is the most common clinical presentation. Appendectomy is the appropriate treatment. Abdomen Rx showed dilated bowel loops in the mid-lower abdominal quadrants. After a negative abdominal ecography, the patient was evaluated by abdominal computed tomography (CT), which revealed the presence of a post-ileal appendix with mild wall thickening and periappendiceal inflammatory changes consistent in acute appendicitis (th post-operative day. Pathological examination showed the presence of a non-mucinous tubulo-villous adenoma with moderate epithelial dysplasia (A 69-year-old Caucasian male with a medical history of hypertension, diabetes mellitus, chronic ischemic heart disease and chronic obstructive bronchopathy, was admitted to the Emergency Department with a two-day history of abdominal pain associated with costipation. Abdominal examination revealed distension with tympanic percussion and the presence of abdominal pain localized, at deep palpation, in the right iliac fossa and in hypogastrium without obvious muscle guarding or rebound tenderness. The patient denied any fever, nausea, vomiting or loss of appetite. Laboratory tests showed a normal white blood cell count of 9.9 × 10ndicitis , withoutndicitis , with asysplasia , Fig. 4 3th–7th decades of life [This case describes an acute appendicitis caused by a rare benign epithelial lesion. Appendiceal epithelial neoplasms are observed in 0.2–0.3% of appendectomy specimens and occur most commonly in the 5 of life . The gre of life . When th of life . Less co of life . Among r of life . In our  of life . Endosco of life , absence of life , low hem of life , outpati of life . In pati of life . In our  of life  and pres of life . Endosco of life . Colonos of life .4Tubulo-villous adenoma of the appendix is very uncommon and mostly discovered after surgery. Preoperative diagnosis is limited because of a frequent lack of symptoms and poor diagnostic signs. Acute appendicitis is the most common presentation and treatment is in any case surgical resection.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Ethical approval has been exempted by our institution because this is a case report and no new studies or new techniques were carried out.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Giuseppe Evola: Operated on the patient, drafting the manuscript.Giovambattista Caruso: Drafting the manuscript and literature research.Sebastiano Caramma: Operated on the patient, literature research.Giovanni Dapri: Revising the manuscript.Carmela Spampinato: Literature research.Carlo Reina: Drafting the manuscript and literature research.Giuseppe Angelo Reina: Clinical supervision and consultation.This case report does not require registration as a research study.The guarantor for this case report is Giuseppe Evola.Not commissioned, externally peer-reviewed.All the authors certify that there is no conflict of interest regarding the material discussed in the manuscript.


Peripheral nerve sheath tumors (PNSTs) may arise sporadically or in the presence of genetic disorders, including neurofibromatosis (NF) types 1 and 2, schwannomatosis, and in patients with large genetic deletions involving the CDKN2A gene. Surgical resection is the treatment of choice for symptomatic PNSTs and offers patients a potential cure; however, pre-existing conditions or tumor location may limit a patient’s surgical options. Radiofrequency ablation (RFA) may provide an alternative therapeutic strategy for the treatment of selected PNSTs that are not amenable to surgical resection. Here, we present a case report of a 49-year-old patient with multiple neurofibromas who underwent RFA treatment of two symptomatic retroperitoneal neurofibromas and review previously reported cases of percutaneous treatment of PNSTs. Although surgery is the current standard of care for the treatment of symptomatic peripheral nerve sheath tumors -3, comorThe patient is a 49-year-old male with longstanding back and left leg pain resistant to pain management. He developed acute worsening of his left sciatic pain and suffered a fall with a left wrist fracture. He subsequently developed shortness of breath and was seen in the emergency room. A computerized tomography (CT) study revealed two right retroperitoneal masses, a right prevertebral lesion measuring 4.1 x 3.6 x 5.7 cm with anterior displacement of the inferior vena cava (IVC) and a right paraspinal lesion centered in the psoas measuring 4.0 X 3.5 x 6.6 cm Figure .The percutaneous biopsy of these lesions was consistent with a benign nerve sheath tumor. He was sent for neurosurgical management and, during his evaluation, was noted to have an 8 x 5 x 5 cm left sciatic tumor Figure .This was excised uneventfully and found to be a Grade I neurofibroma. His chronic left sciatica resolved although his back discomfort persisted.Despite the multiple neurofibromas, the patient did not meet the criteria for NF1. He had a family history of multiple melanomas and other malignancies and was sent for genetic evaluation. He was found to have a large, contiguous genetic deletion of chromosome 9p21.3 extending beyond the cyclin-dependent kinase inhibitor 2A (CDKN2A) gene and spanning approximately 25 genes [His medical comorbidities included uncontrolled insulin-dependent diabetes mellitus with a HgA1C of 11.0, complicated by neuropathy and renal insufficiency, a cerebrovascular disease with two prior cerebral vascular accidents (CVA), and mild residual left hemiparesis, a peripheral vascular disease involving iliac stenting, tobacco abuse, and obesity.The retroperitoneal masses were followed with imaging and were stable for three years. He then developed progressive back and radicular abdominal pain. Imaging revealed the growth of the right prevertebral lesion to 4.4 x 4.0 x 6.2 cm and the growth of the right paraspinal lesion to 4.7 x 4.0 x 7.5 cm Figure . NeitherAt six weeks post-ablation, the right prevertebral lesion had decreased in size to 3.4 x 3.5 x 5.4 cm and the right paraspinal lesion now measured 3.3 x 4.2 x 6.3 cm (figure not shown). Six months after the procedure, he reported his pain had improved. He no longer required methadone for pain control. On the most recent imaging performed four years after the ablation, the anterior prevertebral lesion shows stable regression at 2.9 x 3.3 x 3.5 cm with the posterior paraspinal lesion further decreasing in size to 2.6 x 3.6 x 5.1 cm Figure . Table 1Peripheral nerve sheath tumors (PNSTs) can arise sporadically or in the presence of genetic disorders, such as NF1, NF2, and schwannomatosis, and in association with large genetic deletions involving the CDKN2A gene, as was noted in our patient . In the In addition to expectant management with serial imaging and surgical resection, current alternative therapeutic options for non-cutaneous PNSTs include radiosurgery, cryoablation, RFA, and microwave ablation. The CDKN2A mutation detected in our patient has been associated with sporadic and radiation-associated malignant PNST . Given tSanchez et al. utilized cryoablation for the local tumor control of a recurrent paraspinal plexiform schwannoma in a three-year-old boy. The patient underwent resection of the tumor and re-resection of a recurrent nodule. He then underwent the cryoablation of two subsequent recurrences with good tumor control at the last follow-up . Three aZhao et al. reported on two patients with retroperitoneal nerve sheath tumors treated with RFA. The first patient had a recurrent malignant retroperitoneal schwannoma treated initially with transarterial chemoablation and radiation. As an adjunct, the patient underwent three RFA treatments over a six-month period. The tumor then decreased in size and was stable for over five years. A second patient had a benign, non-operated retroperitoneal schwannoma that also decreased in size and was stable for 27 months . Yan et Ours is the first case of the percutaneous treatment of retroperitoneal neurofibromas. The patient's tumors decreased in size following treatment and have remained stable over a four-year follow-up period. One week after the RFA treatment, the patient’s pain began to improve and he was able to eventually stop his methadone treatment. The case details of all patients, including our case, with the percutaneous treatment of PNSTs are summarized in Table The primary concern regarding the percutaneous treatment of benign PNSTs is that the patient might develop neurological deficits or pain as a result of the treatment, either due to direct nerve fascicle injury or secondary to hematoma formation. Significant pain was noted in two of the patients after cryoablation, as described above, although the pain did improve after approximately one week . No otheFor non-neural malignant tumors, the treatment goal is complete ablation with a treatment margin . For benA tissue diagnosis should be obtained prior to percutaneous treatment since the management of malignant PNSTs is much more aggressive than that of benign lesions. This is particularly important in patients with NF1 who have a higher risk of harboring malignant PNSTs, have a larger tumor burden, and for whom the decision-making process is often more complex than in a patient with a solitary lesion .If the percutaneous treatment of a nerve tumor fails and patients need to undergo surgical resection for continued growth, pain, or a progressive neurological deficit, an additional concern is that prior percutaneous treatment may make subsequent surgical resection more difficult. In Kline’s series, patients undergoing peripheral nerve tumor resection who had a prior biopsy or partial tumor resection were more likely to develop postoperative pain and neurologic dysfunction . WhetherIn a limited number of cases, percutaneous techniques have been used successfully in the management of PNSTs. Further studies in a larger series of patients with PNSTs need to be performed to fully assess the effectiveness of these therapeutic modalities. The exact indications remain to be defined but given the risk of the development of neurological deficits, neurosurgical involvement is critical for safely advancing this field. In the hands of appropriate multidisciplinary teams, these percutaneous techniques have the potential to become powerful adjunctive tools in the treatment of patients with PNSTs.


Florid cemento-osseous dysplasia is a non-neoplastic fibro-osseous lesion which often has an asymptomatic slow growth. Unfortunately, these lesions are usually diagnosed through routine radiographic examination. The aim of this study was to describe the main clinical, radiological and histological characteristics of two case reports diagnosed with florid cemento-osseous dysplasia.Two cases of florid cemento-osseous dysplasia with different clinical and radiological features were presented. Panoramic radiographs showed multiple radiopacities compatible with fibro-osseous lesions in distinct areas of the maxillary bones. The histological study revealed a sclerotic mass which continued imperceptibly with root cement with scarce fibrous lax tissue.The replacement of healthy bone by metaplastic bone and fibrous tissue is the main histological feature. Therapeutic abstention with active clinical and radiographic control visits is recommended in asymptomatic cases. Key words:Fibro-osseous lesions, cemento-osseous dysplasia, florid cemento-osseous dysplasia, gigantiform cementoma, osseous dysplasia. Fibro-osseous lesions of the head and neck were first described by Lichtenstein in 1938 .et al.  classification made in 1971  includedet al.  in 1976 The second classification made by the WHO in 2005  every 8 hours for seven days, 1 capsule of magnesic metamizol, 575 mg  every eight hours for seven days, 1 capsule of ibuprofen 600 mg  every 8 hours for 7 days and one daily capsule of omeprazol 40 mg  in the mornings.An orthopantomography (OPG) and a computerized tomography (CT), which included a 3-dimensional reconstruction of both jaws, were ordered. Radiological imaging revealed a radio-opaque lesion of 1.5 cm surrounded by a sclerotic halo that comprised the apices of tooth 4.7. Furthermore, numerous sclerotic lesions were observed in edentulous sections in those positions concerning teeth 4.6, 3.6, and 3.7, as well as a periapical radiolucent lesion in tooth 1.1 (Fig. The suggested treatment included the surgical extraction of tooth 4.7 and the elimination plus curettage of the residual bone cavity and histological exam of the lesion.Serial cuts on the tooth revealed a significantly thickened root Fig. A. Histol-Case 2A 37-year-old female patient from Morocco with no relevant medical background presented to the Department of Oral Surgery for the assessment and management of numerous mandible fibro-osseous lesions. The patient did not mention previous pain episodes. Vitality tests on the teeth involved were positive, except for tooth 3.7.The OPG revealed a radio-opaque 1.5-cm-in-diameter lesion surrounding the roots of tooth 3.7, whose perimeter was delimited by a radiolucent halo. Numerous lesions with a similar size were observed around the apices of teeth 3.3, 3.5 and 3.6 (Fig. The histological study showed hypercementosis and gutta-percha filling the pulp cavity. The tissue was found to have areas made up of laminar or disorganized bone, and inter-trabecular stroma made up of fibrous tissue with spindle-shaped fibroblasts and absence of cytological atypia. Focally, the lesion presented abundant capillaries and blood extravasation areas Fig. A. The pret al. (FCOD is an infrequent COD that presents numerous radio-opaque lesions which can affect 2 or more maxillary quadrants. FCODs are generally expansive, presented with pain and discharge secondary to infection ,6,7,9,10et al. , reporteAccording to the last WHO classifications ,6, some FCOD has a clear predominance for female patients. Around 90% of cases are diagnosed between the third and fourth decade of life ,6. BlackTherapeutic abstention and periodical controls are preferred in asymptomatic FCODs ,9,10,12.However, when lesions lead to deformations or functional alterations, it is recommended to perform some bone remodeling rather than using wide resection techniques due to the risk of fracture or post-operative infections ,7.FCOD tends to have a scarce vascularization, which paves the way for the infection of these lesions. Any uncontrolled FCOD infection may lead to a chronic diffuse osteomyelitis . Some auImages concerning both cases Fig. A,B show The occurrence of numerous fibro-osseous lesions should include the following nosologic disorders into differential diagnosis: odontogenic cysts, cementoblastoma, osteoma, odontogenic keratocystic, fibrous dysplasia, ossifying fibroma, Paget’s disease, Gardner syndrome, osseous metastases, among others .Sometimes, the biological unspecificity of CODs due to its progressive stages, makes difficult to achieve a diagnostic of CODs. Definitive diagnosis is the result of a histological study supplemented with previous clinical and radiological characteristics.


Splenic flexure volvulus is a rare cause of intestinal obstruction and is uncommonly encountered in young patients from developed countries.This report details a challenging case of a gangrenous large bowel volvulus in a 25 year old woman 20 weeks pregnant, highlighting the diagnostic and operative challenges that this rare clinical situation presents. After urgent MRI confirming a splenic flexure volvulus, an emergency open left hemicolectomy and end colostomy was performed. Following uneventful recovery and successful delivery of her baby at full term, she was reversed 6 months later.Splenic flexure volvulus is a rare cause of large bowel obstruction, and as such can result in a delay in diagnosis, particularly in the setting of pregnancy. In this case, the patient was not diagnosed until day 3 of her admission when she decompensated with a rising white cell count.Splenic flexure volvulus is a rare occurrence. This case report of a young pregnant woman presenting with a large bowel obstruction due to splenic flexure volvulus highlights the importance of considering and investigating for this diagnosis. In 1953 Glazer and Adlersberg reported the first case of splenic flexure volvulus. In 2008 there were less than 100 reported cases in the scientific literature ,5. The f2We present the case of a 25 year old lady from Papua New Guinea who was admitted to the Cairns base hospital (CBH) with a 3 day history of abdominal pain and distension on a background of being 20 weeks pregnant. She had a slightly elevated white cell count upon admission, was haemodynamically stable and tolerating oral diet. The patient had last passed a bowel motion 2 days prior.9/L cells, lactate 3.2 mmol/L and haemoglobin of 126 g/L. An urgent MRI of her abdomen was performed, showing a likely large bowel volvulus with associated free fluid, but no perforation  given she had previous TB and was from an endemic area. On day 3 of her admission she became tachycardic and tachypnoeic with a grossly distended abdomen and worsening abdominal pain. She was febrile with a white cell count of 19 × 10foration , Fig. 2.Given the patients worsening clinical condition and imaging findings she was taken for an urgent laparotomy. A splenic flexure volvulus with gangrenous colon was found , Fig. 4 3The uncommon occurrence of splenic flexure volvulus can be attributed to the splenic flexure being tethered by 3 ligamentous attachments, making it less likely to malrotate . The undrd trimester. [Ballantyne et al 1985) described a single centre series of 137 patients with colonic volvulus over a 20 year period. They described 52% of these as caecal in origin, 43% sigmoid, 3% transverse colon, and only 2% as splenic flexure. [85 descriimester. ,12 A 201In this case there was a delay in the diagnosis due to atypical presentation in an initially stable pregnant women. This delay was due to attributing her symptoms to other pregnancy related conditions, hesitation to use imaging such as X-ray and CT, the rare occurrence of the condition and the patient’s previous diagnosis of TB. MRI was performed due to pregnancy. MRI is not the gold standard for imaging diagnosis of a colonic volvulus, however in situations of a pregnant patient, it should be used to avoid radiation exposure to the foetus.CT scan is typically used for diagnosis, showing the characteristic appearance of markedly dilated, air-filled colon with an abrupt termination at the anatomic splenic flexure . In the 4Volvulus of the splenic flexure is a rare cause of large-bowel obstruction, with predisposing factors including the congenital absence, or surgical excision, of gastrocolic, phrenocolic and splenocolic ligament and the presence of a long mesentery. When these elements are present, the splenic flexure will have higher mobility and risk of volvulus. Splenic flexure volvulus is a rare occurrence in pregnant patients, however this case demonstrates that it should be considered in the differential diagnosis for a patient presenting with acute abdominal pain. Early imaging with MRI in the case of pregnancy is indicated and early surgical intervention once the diagnosis is established.There are no conflicts of interest, financial, personal or otherwise which could influence bias.No funding was needed for this case report, except for the amount required if published.Ethical approval was not required for this case.Consent was obtained from the patient to write this case report using de-identified information and de-identified accompanying radiological and clinical images.Dr Alison Bullen – Corresponding author. Review of patient notes, writing of manuscript, and critically analysed and approved final submission.Dr Joel Lewin – Writing of manuscript, editing and approved final submission.Dr Trent Cross – Critical analysis and revision of draft, approved final submission.Dr Benjamin Woolven – Critical revision of draft and approved final submission.N/A.Dr Trent Cross – General Surgery Registrar, Cairns Hospital, Cairns, QueenslandNot commissioned, externally peer reviewed.