Incidental findings are not uncommon in radiology. In this case, although theincidental findings could be described as an Aunt Minnie, the patient underwentmultiple investigations due to the rarity of the causative parasite. The currentliterature concerning Pentastomiasis suggests it may become more common infuture. Our hope is that this case report will help future patients who presentwith the radiological pattern described to be more rapidly diagnosed andreassured. We report the case of a 49-year-old female of Nigerian origin who was referred forabdominal ultrasound as part of ongoing occupational health testing. The ultrasoundwas unremarkable except for multiple echogenic foci throughout both lobes of theliver  which wee.g. TB or parasitic infection” wasreported.Additional clinical information which was provided with a gastroenterology requestfor repeat ultrasound and a CXR (chest radiograph) included: known hepatitis B , reported right upper quadrant discomfort and “nodules onprevious CXR 20 years ago”. Repeat ultrasound appearances were unchanged. TheCXR showed multiple calcific densities scattered throughout both lungs . Liver e). Multiple appendicular radiographs over this period showed noevidence of peripheral calcific lesions.These calcifications were left unexplained and the patient underwent annualultrasound scans for 5 years. No interval changes were seen over this period.Subsequent history obtained during this follow-up period was of a previous seriouschildhood illness. A pelvic radiograph was obtained following a fall . Multip5 of previous Armillifer armillatus infestation. The clinicalteam were advised elastography would not be accurate due to the extensive hepaticcalcifications and that the patient's hepatic fibrosis was due to theprevious infestation.7In 2017, repeat liver elastography showed a dramatic increase in kPa and concernsabout the hepatic calcifications resurfaced so a biopsy was considered. Prior tothis a CT thorax, abdomen and pelvis (including triple phase liver) was requested.Again, the appearances were unchanged . The repArmilliferidae family are radiologically relevant.4The taxonomy of Pentastomida and the terminology concerning the infections they causeis summarised in Armillifer armillatus and Armillifer moniliformisare endoparasites which feed on blood. They have a "screw like" appearance and canreach up to 20 cm in length.4Armillifer live in the trachea and bronchi of snakes(definitive hosts) such as pythons and vipers.4 Female Armillifer release eggs into the snake’sintestinal and respiratory tracts. When intermediate hosts  come incontact with the sputum/faeces of an infected snake or ingest contaminated water,they themselves can become infected. The Armillifer eggs hatch inthe intestinal tract of their intermediate host and develop into larvae which crossthe gut wall, migrate along the peritoneum or pleura and become encysted in varioustissues; most commonly liver but also spleen, mesentery, intestine, kidney, omentum,peritoneum and lung.10Adult 4The encysted larvae grow slowly and usually die within 2 years. This leads to aninflammatory response which result in absorption or calcification of the dead larvae.Armillifer and the cycle repeats.The life cycle is completed if the intermediate host is ingested by a snakewhilst it hosts live larvae. When the live larvae reach the snake’sintestinal tract they migrate to the respiratory tract, develop into adult5,9,11,12 It later came to light that the patient described in this case has a closefamily member who works with bushmeat.Humans (dead end hosts) are infected by coming into contact with sputum/faeces of aninfected snake, contaminated water or under cooked snake meat.Armillifer armillatus is most commonly seen in West Africa,particularly Nigeria.5,8–13Armillifer moniliformis is more common in Asia.410 In cases which are symptomatic presentation varies according to the tissuesaffected and can range from fever and abdominal pain10,11,13 to intestinal obstruction,3 bacterial septicaemia, severe enterocolitis and death.8 One study showed Armillifer armillatus infection to be thethird most common cause of hepatic fibrosis in Nigeria, which was seen in our caseand previous cases.12Most cases are asymptomatic.11 or laparotomy.4,10 Isolation of live larvae allows histological diagnosis. Serological and PCRtests specific to Armillifer are possible but not usually available.13,14 Patients may have a mild eosinophilia.4,11Diagnosis is usually incidental following radiological investigation, autopsy5 The size of these calcifications varies from 4 to 8 mm.4 Unlike cysticercosis (Taenia solium infestation), themusculature is spared in Armillifer infestation.4 Ultrasound will show multiple hyperechoic lesions in the affected tissues.5,9,11,13 It is worth noting not all cases will present in this way, a case of aPentastomiasis granuloma with the radiographic appearances of hepatic malignancy haspreviously been reported.15 In this case the diagnosis was only reached after surgical resection had beencarried out.15The radiographic appearances are pathognomonic; multiple crescentic, horseshoe,coiled or comma-shaped calcifications distributed mainly within the upper abdomenand thorax.10,13Praziquantel, albendazole or mebendazole have reportedly been successful ateradicating Pentastomida species.4,11,13,14,16Treatment is not required for asymptomatic patients. There is no standard treatmentfor symptomatic patients but surgery might be indicated in selected cases.16 As migration increases, radiographic evidence of previous Armilliferarmillatus infestation may become a more common finding in Westerncountries.Snake meat is becoming more common at bushmeat markets and consumption is increasing.Incidental discovery of the pathognomonic appearances described has in many cases(including ours) led to multiple further investigations before a diagnosis isreached. We hope this case report will help such patients to be more rapidlydiagnosed and reassured.Armillifer armillatus is an endoparasite which lives in therespiratory tract of snakes, it is most commonly found in West Africa.Humans can become infected, especially those from West Africa who handle orconsume snake meat.It is rarely symptomatic.It has a pathognomonic radiological appearance: multiple crescentic,horseshoe, coiled or comma-shaped calcifications distributed mainly withinthe upper abdomen and thorax.Treatment is not required for asymptomatic individuals, there is no standardtreatment for symptomatic patients.The hunting, selling and consumption of bushmeat is increasing. As migrationfrom Africa increases, the radiographic appearances described may become amore common finding in Western countries.


Neurolymphomatosis (NL) is a direct process of invasion of peripheral nerves by lymphoma. It occurs in roughly 5% of patients with lymphoma and represents a particularly difficult diagnostic dilemma when it is the presenting focal manifestation of occult lymphoma.We present 3 examples of invasion of the lumbosacral plexus and its branches. These cases demonstrate a protean clinical picture with regards to the time relationship to the clinical course of lymphoma and the neuroanatomical extent of lumbosacral plexus invasion. We demonstrate the complementary role of different imaging modalities. A review of the literature summarizes 23 reports where lumbosacral plexus invasion was the index manifestation, at the time of first diagnosis or recurrence of lymphoma. This series confirms the strong preponderance of B-cell type (92%). There is a marked predilection for involvement of the sciatic nerve (74%), either focally or in a longitudinally extensive fashion, from the ischium to the popliteal fossa. There can also be restricted and discrete involvement of tibial and fibular branches. In recent years, ultrasound and CT have been given a more limited role, as screening tools or as a guide for biopsy. MRI neurography and PET-CT have become leading diagnostic modalities for diagnosis, staging and assessment of treatment response.The diagnosis of NL may be challenging, and it was once only reached at autopsy. Improved diagnostic imaging of focal or even asymptomatic disease offers new hope for earlier diagnosis and successful targeted therapy. The term neurolymphomatosis (NL) specifically describes a process of direct endoneurial invasion by lymphoma cells –3. All sWe present here 3 patients representative of the spectrum of NL of the lumbosacral plexus and its branches. We have surveyed the relevant literature and discuss the role and sensitivity of neuroimaging techniques.At age 44, this patient presented for the assessment of painful dysesthesia and progressive asymmetric weakness of upper and lower limbs. He had an unrelated past history of grade 2 astrocytoma treated with cranial radiation and temozolomide, with complete remission.The following deficits were noted in the right lower limb: grade 4−/5 paresis of plantar flexion, grade 4/5 paresis of hip extension, and absence of the ankle reflex. These deficits were mostly in the distribution of the S1 spinal root, or tibial division of the sciatic nerve. There was additional multifocal paresis and sensory loss in keeping with bilateral brachial plexopathy. Nerve conduction studies showed proximal motor conduction blocks, normal sensory latencies and amplitudes, and patchy EMG findings of acute denervation. These results were interpreted as favoring a multifocal asymmetric demyelinating sensory and motor neuropathy (MADSAM). The diagnosis appeared to be further supported by the finding of bilateral irregular thickening and enhancement of the brachial plexus on MRI. MRI of the lumbar spine and CSF analysis were unrevealing.18FDG PET-CT study results and pelvic MRI , electron beam therapy, ultraviolet light therapy and methotrexate. At age 74 he developed a progressive isolated left ulnar neuropathy, initially attributed to entrapment at the level of the elbow. There was no improvement after surgical transposition. At age 75, the patient was reassessed, and fusiform enlargement of the ulnar nerve was demonstrated on ultrasound. Exploration and biopsy were diagnostic of T-cell neurolymphomatosis (CD3 positive lymphocytes within nerve trunks highlighted by the S100 stain). Despite targeted radiotherapy to the left arm, there was further proximal extension of lymphomatosis to the brachial plexus. He was treated with additional involved field radiotherapy and combination gemcitabine/decadron chemotherapy.At age 76 the patient reported increasingly disabling new neuropathic pain mostly in the posterior aspect of the left lower limb and plantar surface of the foot. His examination showed greater weakness of plantar flexion and eversion (MRC grade 3/5) than dorsiflexion and inversion (4/5). The left ankle reflex was absent. This assessment was in keeping with a left sciatic neuropathy, with greater involvement of the tibial division. MRI of the lumbar spine without contrast revealed only incidental mild changes of spondylarthrosis. A lumbar plexus MRI with gadolinium, however, better characterized thickening, edema and marked enhancement of the left S1-S3 spinal roots Fig.  as well This patient was 67 years old when she noticed a palpable baseball-sized lump in the distal posterior right thigh.She had several significant medical comorbidities including marked obesity, diabetes type 2, hypertension, atrial fibrillation, congestive heart failure and obstructive sleep apnea.When referred for neurosurgical evaluation, she was found to have complete paralysis of all right ankle movement, but preserved hip and knee flexors and extensors. There was sensory loss in the sciatic territory, with sparing of the femoral cutaneous innervation. The right ankle reflex was absent. Ultrasound (US) of the popliteal fossa Fig.  followedTreatment was initiated with five cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone. There was no clinical improvement with regards to deficits of sciatic neuropathy, but repeat MR imaging Fig.  showed mIn advanced biopsy-proven recurrent or treatment-resistant diffuse large B-cell lymphoma, the occurrence of multifocal radiculopathy, plexopathy or mononeuropathies will immediately suggest a diagnosis of NL . In contIn the absence of documented systemic malignancy, the differential diagnosis of progressive focal neuropathy will include a long list of benign or malignant peripheral nerve sheath tumors , perineuIn Table In the imaging assessment of nerve tumors and the detection of NL, ultrasound is still valuable because of its easy access, safety, lack of contraindications and favorable patient tolerability . It can MRI neurography is emerging as a powerful tool to help detect and characterize nerve pathology . Normal Baehring reported an MRI diagnostic sensitivity of 70% in a series of 40 cases of NL, combining the experience at the Massachusetts General Hospital and a review of the literature up to the year 2000 . Most mo18FDG-PET/CT is a very sensitive technique to reveal hypermetabolic foci, with one study reporting detection of at least one active site in 97% of patients with diffuse large B-cell lymphoma [18FDG-PET/CT has also been shown to be superior to MRI to detect bone marrow involvement in lymphoma [18FDG-PET by itself is a highly sensitive screening tool which offers poor focal spatial resolution, thus it is commonly correlated with CT. Targeted MRI neurography at sites of hypermetabolism can be expected to substantially further improve the anatomical characterization of intraneural invasion. In addition, 18FDG-PET has been demonstrated to be helpful in monitoring the response to therapy [lymphoma . 18FDG-Plymphoma . PET ima therapy , 31.Neurolymphomatosis was once a diagnosis often only reached at autopsy. Advances in neuroimaging offer hope for early recognition, at a stage of discrete unifocal or even entirely asymptomatic lymphoma invasion. Survival rates remain poor with recurrent disease but newer protocols offer hope by combining high-intensity chemotherapy, targeted radiotherapy, immunotherapy (such as chimeric antigen receptor T-Cell) and salvage bone marrow transplantation .


Dear Editor,A 40-year-old man presented with a 12-h history of severe abdominal pain, nausea, andvomiting. Although he reported no comorbidities, he stated that he had concomitantconstipation and had consumed alcoholic beverages over the past three days. Physicalexamination revealed pain on palpation of the lower abdomen. Multidetector computedtomography (MDCT) of the abdomen showed a normal pancreas and tissue formation with adensity of 30 HU, similar to that of the pancreatic parenchyma , located(1-7). Ectopic pancreas is a rare condition that is mostcommon in males between the fourth and sixth decades of life. It is defined aspancreatic tissue in an anomalous location, with no anatomical, neural, or vascularconnection with the normal pancreas(8). Although the pathogenesis of ectopic pancreas isunknown, there are two hypotheses: the first suggests that there is transplantation ofembryonic pancreatic cells to neighboring structures during the intestinal rotationprocess; and the second proposes that embryonic buds remain attached to the primitiveduodenum and, during the growth and formation of the gastrointestinal tract, could becarried to sites proximal or distal to the primitive duodenum(9).Tumors and pseudotumors of the upper abdomen have been the subject of recent studies inthe radiology literature of Brazil. It is important to note that ectopic pancreatic tissueis susceptible to all of the same diseases that effect the nativepancreas(12).The majority of patients with ectopic pancreas are asymptomatic, and the diagnosis isgenerally made on the basis of an incidental finding, either during an imagingexamination or during exploratory surgery motivated by otherdiseases(13).The treatment of ectopic pancreas is directly related to the symptoms and degree ofmalignancy. Resection is recommended for symptomatic patients with lesions greater than3.0 cm and possible malignancy. However, when the lesion is smaller than 3.0 cm or is anincidentaloma, there is still no consensus regarding the choice between resection andconservative percutaneous treatment with periodic surveillance. Resection of an ectopicpancreas can be performed endoscopically or surgically(14) in ectopic pancreatictissue should be addressed in order to avoid neoplasia and infection, facilitatingclinical treatment and periodic surveillance of the patient, in which the radiologistplays an essential role.In conclusion, we believe that, although rare, a pseudocyst


Dear Editor,A female infant was born at term without complications. At 12 days of life, she presentedto a pediatric emergency department for investigation of frequent postprandial vomiting,weight loss, and irritability. According to the mother, she was eliminating urine andfeces. Physical examination revealed abdominal distention. The laboratory findings wereconsistent with iron-deficiency anemia. An X-ray of the abdomen showed gaseousdistention of the stomach and proximal duodenum, without gas in the distal portion,characterizing the typical double-bubble sign . The fin(1-4). Congenital duodenalobstruction is relatively common during the neonatal period. It can be categorized ascomplete or partial and as intrinsic or extrinsic. Extrinsic duodenal obstruction hasmany causes, including annular pancreas, malrotation, and anterior portalvein(5).Acute abdominal conditions are the subject of a number of recent studies in the radiologyliterature(6). Its embryological originbegins between the fifth and seventh gestational weeks, when the two pancreatic buds rotate as part of the process of intestinalrotation. During that period, theduodenum rotates from left to right, the ventral pancreatic bud typically migratesposteriorly and inferiorly, merging with the more caudal portion of the pancreatic headand the uncinate process, and the dorsal bud develops into the body and tail of thepancreas(6).An annular pancreas is due to failure of the ventral bud to rotate, resulting inincarceration of the duodenum(7). In general, an annular pancreas is symptomatic inchildren, especially in the neonatal period(5), the main symptoms being bilious vomitingand abdominal distention(6). In adults, it is typically asymptomatic and isdiagnosed as an incidental finding.Annular pancreas is a rare congenital malformation, characterized by the development of aband of pancreatic tissue that completely or partially surrounds the second duodenalportion, resulting in varying degrees of obstruction(9). In most cases, endoscopy is also performed. However, itshould be borne in mind that even if the radiological and endoscopic findings bothsuggest an annular pancreas, the definitive diagnosis is established only duringsurgery. In patients with symptoms of obstruction, laparotomy can reveal a band ofpancreatic tissue surrounding the second portion of the duodenum, supporting thediagnostic hypothesis, which can be confirmed by examining the resectedspecimen(6).An abdominal X-ray of a patient with an annular pancreas will show the double-bubblesign, indicative of duodenal obstruction. Ultrasound, which is the first-lineexamination in the investigation of abdominal pain in children, reveals afluid-distended duodenum and can identify the second duodenal portion incarcerated bypancreatic tissue. On computed tomography, pancreatic tissue surrounding the duodenumcan also be seen


Traditionally, ultrasound (US)-guided bowel mass biopsies are avoided in favour of endoscopic or surgical biopsies. However, endoscopy cannot easily reach lesions between the duodenojejunal flexure and the terminal ileum and lesions not involving the mucosa may not be accessible via an endoscopic route.The aim of this study was to report our technique and to assess the diagnostic accuracy and safety of US-guided biopsy of bowel masses in children.We conducted a 14-year retrospective review of US-guided bowel mass biopsies at a single paediatric hospital.Twenty US-guided bowel mass biopsies were performed in 19 patients . For 14 biopsies, there was no other lesion that could potentially be biopsied. A percutaneous coaxial technique was used for 19 biopsies and a transanal non-coaxial biopsy was performed in 1. A median of 9 (range: 2–15) cores of tissue was obtained at each biopsy. The technical success rate and adequacy of diagnostic yield were 100%. The most common diagnosis was lymphoma, which occurred in 16 biopsies. Three biopsies contained mucosa. There was one complication out of 20 biopsies : a self-limiting, post biopsy pyrexia. Nineteen procedures were accompanied by a bone marrow aspirate and/or trephine within 2 weeks of the bowel biopsy, only one of which was diagnostic.US-guided bowel mass biopsy can be performed safely in children, with a high diagnostic yield and low complication rate. Traditionally, biopsies of masses arising from the bowel in children are performed endoscopically or surgically, via a laparotomy or laparoscopic approach.The main limitation of performing an endoscopic biopsy of a bowel mass is that the reach of the endoscope is limited to the portions of the gastrointestinal tract between the mouth and the duodenojejunal flexure and between the rectum and the terminal ileum. Consequently, a bowel mass anywhere from the duodenojejunal flexure to the terminal ileum will be beyond the reach of an endoscopic biopsy. Furthermore, endoscopic biopsies are largely limited to the mucosa and submucosa and so intramural, subserosal or exophytic lesions may not be adequately sampled . In suchA percutaneous US-guided approach is an alternative biopsy method. This technique has been described in adults and demonstrated to be both safe and effective  but has This single-centre retrospective study was exempted from institutional review board approval. Data were collected from a single paediatric hospital with a well-established interventional radiology programme. Patients were identified from a prospectively maintained interventional radiology database of biopsies. Inclusion criteria were all patients 0–18 years of age who underwent percutaneous or transanal US-guided biopsy of a bowel mass from June 2004 to January 2018. There were no exclusion criteria. Data sources included the radiology information system picture archiving and communication system, interventional radiology databases and electronic patient records.Demographics recorded included patient age, weight at the time of biopsy and gender. Pre-procedural imaging findings, biopsy technique and histological result, post-procedural clinical course and imaging, and complications were recorded. Complications were graded according to the Society of Interventional Radiology classification of complications . To asseTechnical success was defined as acquiring tissue from the bowel mass using a US-guided biopsy technique. The primary endpoint of clinical success was defined as an adequate diagnostic yield for a definitive histopathological diagnosis to be made. The secondary endpoints were complication rate, type and severity, categorised using Society of Interventional Radiology standards of practice committee classification of complications by outcome criteria . A revieDemographics, technical details and complications were analysed using descriptive statistics. Data are presented as median (range) unless otherwise stated. Further statistical comparison between subgroups was not performed due to the small sample size. Ninety-five percent confidence intervals (CI) were calculated for the proportion of complications.The decision to perform a US-guided biopsy of a bowel mass was made in a multidisciplinary team meeting in conjunction with paediatric oncologists and paediatric surgeons, and after review of relevant prior imaging to ensure the presence of a suitable acoustic window. Pre-biopsy complete blood count and coagulation profile were reviewed and corrected following consultation with the haematology department. All biopsies were performed with the patient under general anaesthesia in an interventional radiology suite. Pre-procedure localisation of the bowel mass was performed with US  and the patient positioned accordingly. Depending on lesion accessibility, either a percutaneous transabdominal or transanal route was chosen. Transabdominal US guidance was used regardless of the approach to the lesion Figs.  and 2. BOver a 14-year period, 20 US-guided bowel mass biopsies were performed in 19 children. Patient characteristics are given in Table Nineteen of the 20 procedures were performed using a percutaneous transabdominal approach. A 15-gauge outer coaxial needle and 16-gauge biopsy needle were used for 14/19 (74%) biopsies and a 17-gauge outer coaxial needle and 18-gauge biopsy needle for 5/19 (26%). All percutaneous biopsies were followed by embolisation of the biopsy tract with compressed gelatin sponge pledgets Figs. . One bioUS-guided biopsy of the bowel mass was technically successful in all procedures. All biopsies yielded an adequate diagnostic yield to allow a histopathological diagnosis to be made Fig. . The hisOf the 19 patients who underwent US-guided bowel mass biopsy, 2 had undergone endoscopic biopsy less than 4 weeks before their radiologic biopsy. Histology from both endoscopic biopsies demonstrated focal active colitis only. On the subsequent US-guided biopsy, one of these lesions was diagnosed as diffuse large B cell lymphoma and the second as necrotising granulomatous inflammation. No patients had a surgical biopsy before or after the US-guided biopsy.Bone marrow aspiration or trephine biopsy was performed within 14 days of 19/20 US-guided bowel mass biopsies. Only 1/19 (5%) showed marrow involvement by the disease process (Burkitt lymphoma); this diagnosis was consistent with the radiologic biopsy result. One out of 19 (5%) showed marrow infiltration by malignant cells but did not give a definite diagnosis, 5/19 (26%) showed reactive marrow changes only and 12/19 (64%) were normal.In the period of follow-up assessed , there was 1 complication out of 20 biopsies . This was a self-limiting post-biopsy pyrexia that lasted for less than 24 h in a patient who was not on antibiotics before their biopsy and was not given intra-procedural antibiotics. This was the patient in whom a transanal biopsy was performed. There was no mucosa found on histological analysis of the sample. This corresponds to a minor A complication with no therapy required and no consequence, according to the Society of Interventional Radiology classification. Three other children were documented to have had pyrexia following their biopsy, but these children had been pyrexial before biopsy, and had been started on a course of antibiotics for this, so this was attributed to their underlying disease process. No patient developed a symptomatic or imaging-detected asymptomatic pneumoperitoneum and no patient required surgery to treat a complication.Percutaneous image-guided bowel mass biopsy has been demonstrated to be both safe and effective in adults  but has Conventionally, biopsies of lesions arising from the gastrointestinal tract are obtained endoscopically. The endoluminal approach is limited to mucosal or submucosal lesions that arise between the mouth and the duodenojejunal flexure or between the terminal ileum and the rectum. Lesions between the duodenojejunal flexure and the terminal ileum are generally beyond the reach of an endoscope. Furthermore, lesions within reach of the endoscope that are intramural, subserosal or exophytic may be impossible to visualise and/or inadequately sampled. In these cases, one could attempt endoscopic US-guided fine-needle aspiration cytology or core biopsy. Endoscopic US-guided fine-needle aspiration has a high degree of sensitivity and specificity in adults . EndoscoThe US-guided approach is an alternative method for obtaining samples of bowel masses for histopathological evaluation. Previously reported sites of percutaneous fine-needle aspiration in adults include the stomach , 11, 12,We have demonstrated that US-guided biopsy of bowel masses can be performed safely and successfully in children. The location of the lesion does not appear to preclude a US-guided approach. Only one mass, arising from the rectum, was thought to be unsafe to biopsy using a transabdominal approach due to the overlying urinary bladder, but it was successfully biopsied using a transanal approach and transabdominal US guidance.In the vast majority of these cases, the underlying pathological process is essentially homogeneous diffuse disease, such as lymphoma and post-transplant lymphoproliferative disease, and the precise site of biopsy is of no particular relevance for establishing or staging the disease. Due to the homogenous nature and diagnostic immunohistochemical profile of most of these disease processes, provided at least some viable tissue is present, the amount of material required is very small. This is in contrast to a biopsy of a lymph node, for example, where there may be only focal involvement; here, the amount of material and specific site of biopsy are of much greater relevance . In thisThere was only one minor  complication of a self-limiting, post-biopsy pyrexia suggesting that the procedure is safe. This case of pyrexia followed the transanal biopsy when pre- or intra-procedural prophylactic antibiotics were not administered. There were at least three percutaneous biopsies in which the bowel mucosa was breached without any complication. These mucosal breaches were non-intentional, and therefore this procedure should be considered “clean contaminated” according to the Society of Interventional Radiology Standards of Practice . Given tAll patients in our study population were inpatients, but given the absence of any major complications it is possible that patients could undergo this procedure during a single-day admission.All procedures in this series yielded a definitive diagnosis and all but one proved to be an aggressive haematological process (lymphoma or post-transplant lymphoproliferative disease). All of these patients were treated medically and did not require surgery, and so US-guided biopsy avoided laparotomy or laparoscopy. Only one patient in the series, in whom the biopsy diagnosed a necrotising granulomatous inflammatory lesion, went on to have an elective laparotomy and left hemicolectomy 8 days after biopsy for surgical resection of this mass.Of the 20 cases in this series, 2 had a prior endoscopic biopsy showing only inflammatory changes of colitis. In these two patients, the subsequent US-guided biopsy showed diffuse large B cell lymphoma and a necrotising granulomatous inflammatory lesion. If US-guided biopsy had not been performed in these patients it would have delayed their diagnosis and management and possibly increased their morbidity.Bone marrow aspirate has routinely been performed as part of lymphoma staging. However, patients with early-stage disease rarely have bone marrow involvement . In thisThis study has several limitations. It is a retrospective review of patients in whom a biopsy was attempted. Patients for whom a US-guided biopsy of a bowel wall mass was requested but not performed after review of available diagnostic imaging  because it was thought to be not technically feasible, and were not included. Therefore, no attempt to assess the proportion of bowel masses that may be suitable for this technique can be made. The nature and location of lesions biopsied were not recorded such that useful data regarding lesion location that may be suitable for US-guided biopsy could be obtained. If conducting a prospective assessment, this information would be useful. There were no cases in which the core biopsies obtained were inadequate for evaluation or in which significant complications arose. However, the number of patients is small.This study demonstrates that percutaneous or transanal US-guided bowel mass biopsies in children are technically feasible. The diagnostic yield in this study was 100% and minor complications occurred in 5%. The procedure avoids the use of more invasive techniques or ionising radiation. The use of prophylactic antibiotics remains controversial. This technique could be considered the first option for diagnosing bowel masses that can be visualised on US, or as an alternative when an endoluminal approach is not possible or has not provided definitive results.


A solid pseudopapillary neoplasm (SPN) is an uncommon pancreatic tumour that usually occurs in young women. Tumours outside the pancreas  are rare. We report a case of an SPN arising from the greater omentum in a 78-year-old male who presented with a month-long history of abdominal pain and a palpable abdominal mass. Laboratory data showed inflammation and anaemia. CT and magnetic resonance imaging revealed a well-defined encapsulated mass measuring 18 cm in the upper right abdomen. The tumour was completely removed via surgery, and pathologic examination confirmed a diagnosis of an SPN in the greater omentum. A 78-year-old male presented at a local hospital with a month-long history of abdominal pain and a palpable abdominal mass. Non-contrast-enhanced CT detected an intraperitoneal mass, and he visited our hospital for further examination. Laboratory data showed inflammation and anaemia. Carcinoembryonic antigen and carbohydrate antigen 19-9 levels were normal.CT revealed a well-defined intraperitoneal encapsulated solid mass with cystic components but no calcification. The mass was 18 cm in diameter, with the solid portion at the periphery. It was located in the upper abdominal region, surrounded by the liver, stomach, transverse colon, and close to the gallbladder . Its maiT1 and T2 weighted images. On the T2 weighted image, the mass was rimmed by low signal intensity and contained fluid–fluid levels. Gadolinium-enhanced dynamic MRI showed early peripheral heterogeneous enhancement of the solid portion with progressive fill-in , cytoplasmic β-catenin, and neuron-specific enolase and negative for AE1/AE3, CAM5.2, E-cadherin, c-kit, desmin, CD34, CD10, progesterone receptors, cyclin D1 and CK19.Based on the morphological and immunohistochemical findings and the absence of a pancreatic mass, the final pathological diagnosis was an SPN arising from the greater omentum. Ten months after surgery, peritoneal metastasis was detected via CT .2SPNs are relatively rare tumours usually found in the body or tail of the pancreas. They typically occur in young women in the second to fourth decade of life. Before being officially designated as SPNs of the pancreas by the World Health Organization in 2000, they were referred to as solid and cystic tumours, solid and papillary epithelial neoplasms, papillary cystic tumours and Frantz’s tumours.18 In these cases, the primary site was the mesocolon, ovary, greater omentum, retroperitoneum or liver. Some SPNs are thought to arise from an ectopic pancreas, while others lack ectopic pancreatic tissue. An ectopic pancreas is detected via autopsy at a reported frequency of 0.6–13.7%. It occurs in the upper gastrointestinal tract, mainly in the stomach, duodenum, and jejunum, but has also been observed in a Meckel’s diverticulum and the ileum, gallbladder and omentum.19Although more and more SPN cases have been reported in recent years, primary SPNs outside the pancreas are exceedingly rare. To the best of our knowledge, there are only 19 cases of extrapancreatic SPNs in the English literature.In the present case, the tumour was located in the upper abdominal region. We believe that it originated in the greater omentum for two reasons: the fibrous portion of the tumour was separated from the stomach and gallbladder, and part of the tumour was in the gastrocolic ligament as determined via microscopic analysis. As further support, CT revealed that the tumour’s main blood supply originated in the branches of the right gastro-omental artery. There was no definitive evidence of an ectopic pancreas origin.20 This hypothesis might explain why the SPNs in the present case and previous cases lacked ectopic pancreatic tissue.The aetiology of SPN development is not well established. Although the immunohistological features of SPNs suggest an epithelial origin, Kosmahl et al. suggest that SPNs arise from genital ridge-related cells that were incorporated into the pancreas during organogenesis.21 However, in the present case, some tumour cells were negative for CD10 and nuclear β-catenin. Although this immunohistochemical pattern was not typical, the appearance of the tumour tissue stained with haematoxylin and eosin was consistent with that of an SPN, hence leading to our final diagnosis of an SPN arising from the greater omentum.SPNs of the pancreas have distinctive pathological features. Microscopically, they display two distinct types of growth patterns, namely, solid and pseudopapillary. The tumour cells are characterized by round to oval nuclei and abundant pale to eosinophilic cytoplasm. On immunohistochemistry, they typically express vimentin, CD10 and nuclear and cytoplasmic β-catenin, but not chromogranin A.T2 weighted images. Areas of high signal intensity on T1 weighted images and fluid-fluid levels within the mass on T2 weighted images can help identify blood products.2 The imaging features of the extrapancreatic SPNs in the present case and previous cases were similar to those of conventional pancreatic SPNs.The classic CT feature of pancreatic SPNs is a large well-encapsulated mass with varying amounts of solid and cystic components that reflect the degree of haemorrhagic degeneration. Calcification may exist at the periphery of the mass. Contrast-enhanced dynamic CT scans show early peripheral heterogeneous enhancement of the solid portion of the mass with progressive fill-in. MRI typically shows a well-defined heterogeneous mass with thick fibrous capsule that appears as a discontinuous rim of low signal intensity on Pancreatic SPNs have a limited malignant potential, and hence tend to have a favourable prognosis with little local recurrence in studies with long-term follow-ups. Although extrapancreatic SPNs are similar in these respects, careful follow-up is needed because some SPNs can metastasize as is the present case.Primary SPNs occurring outside the pancreas are exceedingly rare.The imaging features of extrapancreatic SPNs in the present case and previous cases are similar to those of conventional pancreatic SPNs.Although preoperative diagnosis of an extrapancreatic SPN remains challenging, the presence of an encapsulated solid and cystic mass with calcification and haemorrhage is at least suggestive of this diagnosis.Informed consent was obtained from the patient after explaining the publication process and use of images.


CT scan is the key for internal hernia diagnosis and management.•High index of clinical suspicion and early intervention saves the patient from extensive bowel resection. Pericecal hernia is a rare cause of small bowel obstruction. They tend to affect the adult population more commonly but also may occur in the pediatric age group.We herein present a 16-year-old male who presented with 4 days of abdominal pain and distention. CT scan revealed evidence of dilated small bowel loops with evidence of ischemia. A laparotomy was performed and revealed a 20 cm segment of distal ileum protruding through the superior ileocecal recess. Ileocecectomy with primary side to side anastomosis was successfully performed and the patient recovered uneventfully after the procedure.Although internal hernias may have a congenital etiology, most of the reported cases have occurred during adulthood and its presentation in childhood is uncommon. CT scan is the key for internal hernia diagnosis and management as it provides information about the presence of bowel obstruction, strangulation, and ischemia.High index of clinical suspicion and early intervention saves the patient from extensive bowel resection and other serious complications. They are classified into congenital and acquired hernias. Congenital hernias are usually caused by abnormal anatomic structural defects such as paraduodenal, transmesenteric, pericecal, transmesosigmoidal, supra- or perivesical, through Winslow’s foramen, omental hernia, and rarely, hernia through the broad ligament, the mesoappendix, or the mesentery of a Meckel’s diverticulum . In contThe reported incidence of internal hernias ranges from 0.6% to 5.8% of all small bowel obstructions . InternaPericecal hernias are responsible for 0.1–6.6% of internal hernias . In mostThis case report has been reported in line with the SCARE criteria .2A and B). Based on this clinical presentation, the patient received an initial diagnosis of small intestinal obstruction and he was taken to the operating room. He was initially investigated with laparoscopy which revealed severe ischemic distal ileal segment. It was difficult to continue laparoscopically due to the severe small bowel dilatation (A 16-year-old male with unremarkable past medical or surgical history presented to the Emergency Department with progressively worsening abdominal pain and distention of 4 days’ duration. His vital signs were within normal limits. On physical examination, he had generalized abdominal tenderness and guarding of the abdomen. Laboratory findings were significant for an abnormally elevated white blood cell count of 24,900/mm3 but otherwise insignificant. A plain abdominal x-ray showed multiple air fluid levels. A computed tomographic scan showed a small amount of free fluid in the abdomen and dilated small bowel loops with evidence of ischemia A and B. latation . We convlatation . During 3Internal hernia is the protrusion of visceral contents through a congenital or an acquired opening within the peritoneal cavity. It has an incidence of less than 1% and is significantly less common than external hernias . AccordiAlthough internal hernias may have a congenital etiology, most of the reported cases have occurred during adulthood and presentation in childhood is uncommon . The mosPericecal hernias are responsible for 0.1–6.6% of internal hernias . During Upon literature review, three cases of pericecal hernia in the pediatric population were reported .Table 1APreoperative diagnosis of internal hernia is difficult because symptoms may range from intermittent and mild digestive complaints to symptoms of acute-onset intestinal obstruction. Internal hernias are silent if they are easily reducible, but the majority often cause epigastric discomfort, periumbilical pain, and recurrent episodes of intestinal obstruction . InternaKeeping in mind the risk of CT radiation, especially in children. CT scan is the key for internal hernia diagnosis and management as it provides information about the presence of bowel obstruction, strangulation, and ischemia. It aids in preoperative planning and when to urgently surgically intervene. CT appearance of a pericecal hernia is not established as there are few cases in the literature . A CT scTreatment of an internal hernia with signs of bowel obstruction includes volume resuscitation, correction of electrolyte imbalances and surgery. Laparotomy has generally been the preferred approach for the presence of small bowel obstruction. Technical difficulties and potential complications such as having no work space from distended small bowel loops and the inability to visualize the transition point make laparotomy more preferred over laparoscopy. However, laparoscopic approach has shown safety and efficacy in select cases . Benefit4Pericecal hernia in a pediatric patient is rare but should be included in the differential diagnosis of small bowel obstruction. CT imaging is the imaging study of choice that aids in the diagnosis and management of pericecal hernia. High index of clinical suspicion and early intervention saves the patient from extensive bowel resection and other serious complications.The authors declare that they have no conflict of interest regarding the publication of this case reportNo funding was sought or secured in relation to this case report.This is a case report, ethical approval not applicable.Written informed consent was obtained from the patient for publication of this case report and accompanying image. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.These authors contributed equally to this work. Loay M. Aljaberi wrote and reviewed the manuscript. AlaaEddin Salameh, Raed M. Mashalah, & Ayman AbuMaria reviewed the manuscipt.This is a case report, registration of research studies not applicable.Ayman Abu Maria, MD.Not commissioned, externally peer-reviewed


Primary appendiceal cancer with fistula formation is extremely rare. We report a case of a patient with appendiceal cancer invading the ileum who underwent successful laparoscopic ileocecal resection.A 76-year-old man who presented with fever and abdominal pain was diagnosed with acute appendicitis and received antibiotics at a local hospital. After a few days, he was referred to our hospital because of an abnormality found in the colonoscopy, which was an oozing ulcer in the terminal ileum. Laparoscopic ileocecal resection was performed with a preoperative diagnosis of ileal cancer. The tumor adhered to the right internal inguinal ring. We dissected the right spermatic cord involved in the tumor. The resected specimen revealed a fistula between the appendiceal orifice and ileac ulcer. Histopathological examination revealed a well differentiated tubular adenocarcinoma. We made the diagnosis of appendiceal cancer with an ileal fistula because the ileal ulcer was derived from the appendiceal site.Most cases of appendiceal cancer with a fistula undergo laparotomy, but in selected cases, laparoscopic resection should be considered a feasible, safe, and curative procedure. Our patient underwent laparoscopic ileocecal resection, whereby the tumor and other organs with invasion were resected successfully with a negative surgical margin.This is the first case report of appendiceal cancer with an ileal fistula successfully treated with laparoscopic resection. Laparoscopic ileocecal resection can be applied for appendiceal cancers with a fistula by experienced surgeons with careful consideration. Appendi2A 76-year-old man who presented with fever and abdominal pain was diagnosed with acute appendicitis and received antibiotics at a local hospital. After a few days, he received a colonoscopy, which revealed a mass in the terminal ileum, and was then referred to our hospital. He had a past medical history of hypertension and a family history of paternal pancreatic cancer and a brother with prostate cancer. Physical examination revealed a blood pressure of 140/82 mmHg, pulse rate of 82/min, and temperature of 35.5 °C. Abdominal examination revealed an elastic hard mass with mild tenderness and a diameter of about 5 cm in the right lower quadrant. His abdomen was soft and flat, and he had no peritoneal signs. Laboratory data showed a white blood cell count of 9600 μ/L, C-reactive protein value of 0.26 mg/dl and CEA level of 6.4 ng/ml . A colonoscopy exam revealed an oozing ulcer in the terminal ileum . FluorosA laparoscopic ileocecal resection was performed after the patient gave informed consent regarding the surgical technique, possible complications, and the possibility of conversion to conventional open surgery. With the patient in a supine position and legs apart, we made an incision in the umbilicus and a 10-mm trocar was introduced. After setting the pneumoperitoneum to 10 mmHg, a 5-mm trocar was introduced intraperitoneally into the right lower abdomen and left abdomen, respectively, and a 12-mm trocar was similarly introduced into the left abdomen. A tumor surrounded by fatty tissue and omentum was located in ileocecal area and adhered to the right internal inguinal ring A. We disThe resected specimen revealed a fistula between the appendiceal orifice and ileac ulcer . Histopa3A PubMed database search for the period from January 1980 to August 2018 was performed using the key words “appendiceal cancer” and “ileac fistula”. The search identified only one English language report which was written by Nakada et al. . They reAppendiceal cancer most often presents with acute appendicitis or a palpable abdominal mass, and some of these tumors are entirely asymptomatic. Preoperative diagnosis is difficult because of poorly defined characteristic findings. Wang et al.  reportedSurgical resection is the only curative treatment for appendiceal cancer. In previous reports, all cases received surgery, with 4 of the 5 reported patients undergoing open radical surgery. One received non-curative open surgery with ileocecal resection and closing of other sites of the fistula. Our case underwent laparoscopic ileocecal resection, whereby the tumor and other organs with invasion were resected successfully with a negative surgical margin. Most cases with fistula undergo laparotomic surgery, however, in selected cases, laparoscopic resection can also be feasible. Indeed, some surgeons have reported the beneficial aspects of laparoscopic resection of appendiceal tumors . The lapRegarding oncologic safety, extreme attention must be paid not to disseminate malignant cell intraperitoneally. Surgeons should use non-traumatic endo-laparoscopic forceps in order not to crush the tumor. A wound protector or a plastic pouch should be used to transport specimens. Surgeons should discuss carefully with surgical colleagues whether to convert to open surgery in cases that tumor adhesion or extension of the intestine prevents a good surgical view. When complying with these suggestions, the laparoscopic approach not only allows for resection of early appendiceal cancer but also for advanced disease, such as with a fistula with other organs. Appendiceal cancer tends to be associated with a poor prognosis, and fistula formation usually indicates deep invasion and advanced cancer. However, this may not always mean that non-curative surgery can be undertaken, because fistula formation sometimes prevents peritoneal dissemination. A previously reported patient has been alive for 9 years after surgery without recurrence .4This is the first case report of appendiceal cancer with an ileal fistula successfully treated with laparoscopic resection. Our patient underwent laparoscopic ileocecal resection, whereby the tumor and other organs with invasion were resected successfully with a negative surgical margin. In selected cases, laparoscopic ileocecal resection can be applied for appendiceal cancers with a fistula by experienced surgeons with careful consideration.We have no conflicts of interest to disclose related to this work.We have no funding for this work.Ethical approval is not needed for this case report as patient consent.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.JM and YS drafted the manuscript. KK, YS, HH, MS, SK, YM, KY, TN, SS and YK contributed to patient care. JM, YS and KK performed the literature search. YS, KK and YK participated in the critical revision of the manuscript. All authors have read and approved the final manuscript.https://www.med.or.jp/english/wma_pdf.pdf).It is the institutional policy at Kobe University that a single case report (three or fewer cases) does not require an Institutional Review Board review or a Research Registry Number. This is also in compliance with the Japanese Care Act and the provisions outlined by Japanese Medical Association at the International Conference at JMA, Japan 2017. (The patient in the case report has been completely de-identified, no information or photos in the report can be used to trace the patient's identity and the report is not an investigation of an FDA regulated product, and therefore is considered as an exempt study/report. All relevant privacy regulations, including the HIPAA privacy policy have been followed in the preparation of this report.I, Junko Mukohyama, MD, PhD, am affiliated with Kobe University and in full compliance with all Rules and Regulations governing patient care. I accept full responsibility for the work and/or the conduct of the study, had access to the data and controlled the decision to publish.Not commissioned, externally peer reviewed.


Chylous ascites is considered to be an intra-abdominal collection of creamy colored fluid with triglyceride content of > 110 mg/dL. Chylous ascites is an uncommon but serious complication of numerous surgical interventions. However, it is a rare complication of LRYGB. An internal hernia limb defect is thought to be the underlying etiology, where the hernia will cause lymphatic vessel engorgement and lymphatic extravasation.We report a case of a 29 years old male with a 9 year history of laparoscopic Roux en y gastric bypass (LRGYB), presenting with recurrent abdominal pain for 2 months radiating to the right shoulder. Ultrasound examination revealed gallstones and the patient was subsequently admitted for laparoscopic cholecystectomy. Intraoperatively, whitish colored fluid, high in triglycerides content was aspirated. During exploration, an internal hernia limb defect was found and corrected.Post LRGYB patients with symptoms of recurrent abdominal pain should be suspected for chylous ascites reflecting an internal hernia. Chyloperitoneum is defined as the accumulation of lymphatic fluid in the peritoneum due to leakage/break in the lymphatic system. Three reasons have been thought to cause this accumulation: 1) Obstruction of the vessels by a mass or tumor, leading to exudation through dilated lymphatic vessel’s wall or rupture of the vessel. Usually, these patients develop protein losing enteropathy. (2) Formation of a fistula between the lymphatic vessels and the peritoneum or mesentry secondary to adhesions, trauma or surgery. (3) Leakage from the retroperitoneal megalymphatics with or without an evidence of fistula, usually as a consequent of congenital diseases. In order to define ascetic fluid as chyle, the triglyceride content of the fluid must be greater than 110 mg/dl (2 to 8 times higher than plasma levels) and its specific gravity greater than 1.012. It commonly has the appearance of a turbid, milky fluid with no odor [ ObstructChylous ascites has been reported to be most commonly due to malignancies in adults. In post-surgical cases, it has been most related to either vascular or lymphatic related operations . HoweverA 29-year-old male, with a known surgical history of LRYGB 9 years ago, presented to the emergency department complaining of sharp, severe abdominal pain in the right upper quadrant (RUQ). The pain began two months ago in an intermittent fashion that would occasionally radiate to his right shoulder and progressively became worse with time. The patient did not report any constipation, distension, or vomiting despite feeling nauseated during these attacks. The pain was not related to any movement or meals and it was moderately relieved by over the counter analgesia.2. He underwent a successful LRYGB with no complications or readmissions. After the surgery for a year and a half, he followed up with his primary surgeon. During that time, he lost 75 Kg, reaching a BMI of 26.9 Kg/m2. He then was able to maintain his weight following the operation, but failed to continue to follow up for the past 2 years. In those 2 years, he gained weight, raising his BMI to 29.9 Kg/m2, after which he modified his diet to reduce his BMI to 23.9 Kg/m2. This weight reduction was achieved prior to his presentation.Ten years ago, the patient was diagnosed with obstructive sleep apnea (OSA), through a sleep study, due to morbid obesity. He then was advised to undergo LRYGB as a treatment. He does have any other medical problems. Family history is notable for diabetes mellitus and hypertension but no history of hyperlipidemia or obesity. His body mass index (BMI) prior to the surgery was 49.3 Kg/mOn physical examination, the patient was afebrile with normal vital signs. Examination of his abdomen revealed moderate tenderness over the epigastrium, central abdomen, and right hypochondrium with a positive Murphy’s sign. His laboratory investigations, including complete blood count, urine analysis, liver and renal function tests, were all within normal limits. An ultrasound examination revealed two gallstones and upper borderline diameter of common bile duct, raising the suspicion of biliary obstruction.Correlating his investigation results with his symptoms, he was admitted and scheduled for a cholecystectomy. Formal laparoscopic cholecystectomy was carried out the next morning. During exploration, twisting of the common channel was observed, indicating an internal hernia, although the patient’s complaint did not suggest internal hernia in the differential diagnosis. The internal hernia was identified but reduction was not feasible through laparoscopy. Mini midline laparotomy was subsequently done for reduction of the hernia and more detailed exploration. The hernia was through the mesenteric defect between the alimentary limb and the biliopancreatic limbs. Both limbs of the anastomosis were identified and complete reduction of the internal hernia was done, in addition to suturing of the defect found in the mesentery. No other defects were found. The small intestine’s mesentery showed prominent whitish colored vessels. Whitish thick fluid was noticed, accumulating in the right paracolic gutter and in Morison’s pouch. All of the fluid was then aspirated, measuring a total of 752 mL. Analysis of the fluid showed a triglyceride level of 534 mg/dL and a Lactate Dehydrogenase (LDH) level of 512 U/L. A classic Blake drain 24 F was inserted into the pelvis. The patient passed an uneventful post-operative period. On Postoperative Day (POD) one, fluid collected from the drain was 440 ml, chylous in appearance, while on POD 2–4 the drainage was serous in appearance. The drain was removed on POD 4. The patient was discharged on POD 4 after being able to ambulate independently on his own and eat and drink with no complications.The patient did not return back for his follow-up visits and when he was called by the team, he confirmed that he has no complains up to this day.Obesity is still considered a major burden worldwide. Obesity is defined as a BMI > 30 kg/m2. The World Health Organization (WHO) has reported that in 2016, 13% of the world’s adult population were obese, with obesity prevalence doubling between 1975 and 2016 .Several approaches have been addressed worldwide to treat obesity and prevent its complications. However, lifestyle modifications and medical therapy are not always effective, especially in cases involving morbid obesity. Therefore, bariatric surgery is an indication for treating obesity with a BMI above 40 kg/m2 or a BMI above 35 kg/m2 with comorbidities, according to the latest consensus guideline by the American Society for Metabolic and Bariatric Surgery (ASMBS). Of the various bariatric surgeries, LRYGB is considered the gold standard in treating obesity. Nevertheless, like any surgical procedure, LRGYB has a risk for developing several complications, several of which require repetitive follow-up postoperatively –9.Internal hernia is one of the most common complications of LRYGB . The preIt was reported from a review of several studies that the incidence of internal hernia after a LRYGB was between 0.2–8.6%. The most common presentation was small bowel obstruction symptoms, ranging from 1.8–9.7% after a LRYGB .Typically, patients with internal hernia have a chronic recurrent presentation of colicky abdominal pain, nausea and vomiting. The presence of an internal hernia increases the risk of developing small bowel obstruction as a sequela, usually presenting in a late stage .In our case, the patient presented with the typical symptoms of biliary colic, which was supported by the presence of gallstones on ultrasound. This presentation masked the real patient’s problem; an internal hernia leading to chylous ascites.Internal hernia can occur due to a surgical defect, depending on whether a retrocolic or antecolic approach is utilised. Petersen’s defect is the presence of space between the Roux limb and the transverse mesocolon. A second defect might also be present between the biliopancreatic and Roux limbs at the jejunojejunostomy. In cases of retrocolic approach, a third defect in the transverse mesocolon might be created. This is the most common reported site of internal hernia, prompting several surgeons to adopt the antecolic technique to eliminate such defect. In addition, the latter is consistent with an intermittent internal hernia that has the potential to reduce itself spontaneously, which explains the recurrent pain that our patient was having. Review of the literature supports the antecolic technique, as lower rates of herniation were reported when compared to the retrocolic technique. Most of internal hernias can be successfully treated laparoscopically, through the reduction of the herniated limb and the closure of the mesenteric defect. However, due to the fact that laparoscopy procedures possess a lower risk of adhesion formation, this can contribute to the risk of hernias by allowing more intestinal movement around a potential mesenteric space. Thus, laparotomy may help reduce the risk of developing internal hernia, as a result of more adhesions presence. .Up to our knowledge, only three cases of chylous ascites post LRYGB were reported. An average time for presentation with chylous ascites in these cases was 20 months , 5. In oHidalgo et al. reported a 40-year-old morbid obese patient with comorbidities of exertional dyspnea and joint disease who underwent a LRYGB 15 months prior to his presentation. He presented with mild chronic abdominal pain and nausea. A computed tomography showed intra-abdominal fluid collection. The patient was taken for a diagnostic laparoscopy where a common channel internal hernia was identified and corrected. In addition, milky fluid was extracted and analyzed, with reports showing high triglycerides levels .Hanson et al. reported a 22-year-old woman presenting with severe abdominal pain 2 years after undergoing LRYGB, during which she lost 90lbs. Computed tomography showed a huge collection of mesenteric free fluid, necessitating an urgent operation. Intraoperatively, a mesenteric defect was identified, in which the common channel was fully herniating through. 4 l of free fluid was extracted with the analysis reporting a triglycerides level of 388 mg/dL [Capristo et al. reported a 61-year-old heavy smoker and heavy alcohol drinking man who underwent a LRYGB 18 months prior to the presentation of a sudden weight gain of 5 Kg, abdominal distention and shortness of breath. His BMI was reduced from 41.8 kg/m2 to 31.7 kg/m2. On physical examination, the patient had significant ascites, right pleural effusion and left supraclavicular lymph node enlargement. Paracentesis and thoracentesis evacuated a total of 4.5 L of whitish fluid, high in triglycerides. However, lymph node biopsy, computed tomography and positron-emission tomography revealed a poorly differentiated gastric carcinoma. This finding indicated that the chylous ascites was not related to the LRYGB [These cases along with our case showed that chylous ascites is a manifestation of an internal herniation from a mesenteric defect after a LRYGB. These cases might present with vague or misleading symptoms.Physicians, including general practitioners and emergency doctors, should have a high index of suspicion for internal hernia for post LRYGB patients, even if they present with mild to moderate symptoms of abdominal colicky pain. A delayed diagnosis of internal hernia increases the risk of developing acute small bowel obstruction. Such cases should be transferred to bariatric surgery if possible or undergo laparoscopic exploration, as it is the most sensitive and specific diagnostic tool, compared to imaging such as Computed Tomography (CT) scan which does not help in diagnosis .In conclusion, our case was about a patient who developed chylous ascites 9 years after he underwent a LRYGB. While the most common cause of chylous ascites in adults is malignancy, it can also be an unusual presentation due to internal herniation that arises from a mesenteric defect post LRYGB. Chylous ascites in these case present with very mild and vague symptoms that might deviate the differential diagnosis away from a possible internal hernia. Thus, chylous ascites should be suspected in all LRYGB patients presenting with mild abdominal symptoms and properly managed accordingly.


Physical examination revealed a back abrasion, stupor, and spasmodic laughter  is rare.What do we already know about this clinical entity?Malignant catatonia (MC) often leads to fatal consequences. Administration of low-dose lorazepam typically leads to rapid resolution of symptoms; thus, definite diagnosis is crucial.What is the major impact of the image?Because MC resembles tetanus, diagnosis is often difficult and delayed.How might this improve emergency medicine practice?Administration of low-dose benzodiazepines may be warranted when patients presenting with MC symptoms have a history of psychological disorders and normal blood, urine, cerebrospinal fluid testing and imaging.Documented patient informed consent and/or Institutional Review Board approval has been obtained and filed for publication of this case report.


Intracholecystic papillary neoplasm (ICPN) is defined as papillary tumors detected macroscopically in the gallbladder. We report a case of ICPN which exhibited the atypical form like a submucosal tumor.A 70-year-old man was admitted to our hospital because of hepatic disorder. Computed tomography and magnetic resonance imaging showed irregular thickening of the wall within the gallbladder fundus. Because the lesion might have been malignant, we performed laparoscopic cholecystectomy and liver bed resection. Macroscopic findings showed the mucosal surface of the tumor was smooth, and its form was similar to that of a submucosal tumor. Histopathological examination revealed papillary tumors within the mass with low-grade dysplasia; therefore, we diagnosed ICPN.In the present case, ICPN was resembling a submucosal tumor macroscopically because the tumors arose into the Rokitansky-Aschoff sinus and the adenomyomatous hyperplasia was merged with the ICPN. It is necessary to consider the possibility of tumor lesions within adenomyomatous hyperplasia. Intracholecystic papillary neoplasm (ICPN) is preinvasive neoplastic lesions characterized by papillary growth in the gallbladder. ICPN is defined as gallbladder lesions of intraductal papillary neoplasm of the bile duct (IPNB). IPNB is a premalignant lesion of the biliary tract and is counterpart of intraductal papillary-mucinous neoplasm (IPMN) in the pancreatic duct epithelium . ICPN isThrough this case, we consider clinicopathological characteristics and therapeutic strategies of ICPN.The patient was a 70-year-old man. He was admitted to our hospital because of a hepatic disorder that was discovered during a routine health examination. Blood tests showed aspartate aminotransferase 48 U/L , alanine phosphatase 66 U/L , alkaline phosphatase 263 U/L , gamma-glutamyl transpeptidase 100 , total bilirubin 0.5 mg/dL , carcinoembryonic antigen 4.4 ng/mL , and carbohydrate antigen 19-9 10.4 U/mL . Abdominal ultrasonography showed an 8 × 7-mm solid mass at the gallbladder fundus and several stones in the gallbladder Fig. . EnhanceICPN was first described as gallbladder lesions of IPNB in the 2010 WHO classification and was classified as premalignant lesions of biliary system in the same category as adenoma, biliary intraepithelial neoplasia, and mucinous cystic neoplasm . It is aThe histopathological characteristics of ICPN are equivalent to IPNB. Four histological subtypes exist, including biliary type, gastric type, intestinal type, and oncocytic type according to IPMN. The mucus glycoprotein expression form is different depending on each histological subtype; that of early biliary carcinoma differs from ICPN , 6. AbouICPN shows various degrees of dysplasia from low- to high-grade and finally to invasive carcinoma, and the histological findings are often mixed . This vaHowever, the concept of ICPN remains unclear about several points.First, it is difficult to distinguish ICPN, including widespread infiltrating cancerous regions, from gallbladder carcinoma, including papillary tumor regions. It is important to distinguish both for selecting an appropriate treatment strategy. If ICPN is diagnosed preoperatively, simple cholecystectomy can be performed without lymphadenectomy. Second, management for tubular components in ICPN is controversial. There is no clear description about it in the 2010 WHO classification. Adsay et al. defines ICPN as an exophytic intramucosal gallbladder mass greater than 1 cm and composed of dysplastic cells forming a lesion distinct from the neighboring mucosa . AccordiIn the present case, the tumor’s mucosal surface was smooth and its form was similar to a submucosal tumor. Although the macroscopic findings were atypical, histopathological examination showed papillary tumors with low-grade dysplasia and mucin secretion and ICPN was diagnosed. The RAS was formed, the smooth muscle became hyperplastic in the stromal tissue, the tumors arose into the RAS, and the adenomyomatous hyperplasia was merged with ICPN. Thus, the tumor formed like a submucosal tumor.Although histopathological findings showed papillary tumors with cystic formation, preoperative CT showed only wall thickening and did not show cystic formation findings. It was considered that because the cysts were involved in hyperplastic smooth muscles, the imaging could not detect the cystic formation. On the other hand, the high-intensity punctiform lesions were detected by T2-weighted MRI. It was considered that the finding demonstrated the tumors rise into the RAS, and the cysts were formed.Although gallbladder adenocarcinoma or ICPN rising in RAS have been reported, to our knowledge, this is the first case of ICPN with adenomyomatous hyperplasia . It is nWe report a case of ICPN that was resembling a submucosal tumor because the tumors rose into the RAS, and adenomyomatous hyperplasia was merged with ICPN. It is necessary to consider the possibility of tumor lesions within adenomyomatous hyperplasia.


We report an occurrence of periosteal chondroma seeding into the medulla of humerus via percutaneous needle biopsy tract. To our knowledge, this is the first described case of benign cartilage tumour biopsy tract seeding in the literature. We discuss the clinical, radiological and histological features of periosteal chondroma, as well as the diagnostic challenges associated with distinguishing this entity from periosteal chondrosarcoma. Finally, we briefly discuss the safety of imaging-guided percutaneous needle biopsy and methods to minimize the risk of iatrogenic tumour seeding. T1 weighted sequences showed the lesion to be isointense relative to adjacent muscle. There was low-grade peripheral contrast enhancement  . The tisThe patient re-presented 10 months later owing to worsening pain. MRI showed the original lesion had developed a cartilaginous, multilobulated component, invading through the cortical biopsy tract into the medulla . Repeat Wide-margin surgical resection was performed, confirming the presence of periosteal chondroma with extension through a cortical deficit into the underlying medulla . The medPostoperative recovery was uncomplicated. The patient was reviewed 3 months postoperatively and had no further left proximal arm pain.We present a unique case of intramedullary seeding of periosteal chondroma following iatrogenic trauma from percutaneous core needle biopsy. Invasion of a cartilaginous mass, such as periosteal chondrosarcoma, into an extra-anatomical compartment is a characteristic previously believed to be exclusive to malignant lesions.1Periosteal chondromas are benign cartilaginous growths originating from the deep surface of long bone periosteum. Together with periosteal chondrosarcoma, these lesions represent approximately 1% of all bone neoplasms.4 Regarding the assessment of cartilage tumours, Bauer et al1 suggest that isolated pain in the absence of preceding trauma may be owing to the aggressive biological behaviour of a lesion such as periosteal chondrosarcoma.Periosteal chondroma commonly presents with pain; however, it typically has a gradual onset of several years and is usually associated with a mass or previous traumatic episode.2Periosteal chondromas are usually well marginated on radiographic evaluation with sharply demarcated saucerization of adjacent bone cortex, often demonstrating adjacent cortical destruction lending a scalloped appearance; in some cases, the cortical bone may be seen to enclose the lesion with partially overhanging edges.T1 weighted MR sequences, periosteal chondromas demonstrate hypointense to isointense signal relative to muscle.5T2and T2* weighted sequences characteristically demonstrate the lesion to be hyperintense relative to fat, attributable to the high water content of hyaline cartilage; a peripherally based hypointense lining correlating to intact periosteum is also usually seen.5 Bone marrow or surrounding soft tissue oedema are rare features.5 Following the administration of gadolinium-diethylenetriamine pentaacetic acid Gd DTPA contrast, Woertler et al5 described enhancement of the lesion periphery in 100% of cases.On 2 Histological analysis of periosteal chondromas demonstrates lobules of immature hyaline cartilage with small chondrocytes present. Additionally, these lesions may feature cellular atypia, hypercellularity, multinucleation, hyperchromatic nuclei or myxoid change in the matrix, making them difficult to distinguish from low-grade chondrosarcoma.It is recognized that the histological characteristics of periosteal chondroma can vary from bland cartilage to low-grade cancer, whereas chondrosarcomas have been shown to always meet the histological criteria of a malignant diagnosis.Discerning periosteal chondroma from periosteal chondrosarcoma can be difficult. Lesion size can be useful in differentiating these entities. The average size of periosteal chondroma has been shown to vary from 2.2 to 2.8 cm, with no lesion greater than 7 cm being reported in the literature.3 in a study correlating the histological and radiological findings of cartilaginous periosteal lesions, where medullary invasion of periosteal chondroma was reported on CT and MR imaging in 4 out of 22 patients. The reporting osteopathologist was blind to the radiological findings in each case. Given the recommendation from several authors that differentiation of periosteal chondroma from low-grade periosteal chondrosarcoma be made by collaborating clinical, radiological and pathological data rather than based solely on histopathology, it is possible these four cases may have been reported as chondrosarcoma if the osteopathologist had access to the radiological studies.Periosteal chondroma was previously thought to be distinguishable from periosteal chondrosarcoma by the absence of medullary invasion.The lesion identified in our study did have well-defined margins and measured less than 3 cm in maximal dimension, supporting the diagnosis of periosteal chondroma. However, the recent onset of pain in the absence of trauma could have been owing to a low-grade periosteal chondrosarcoma. At our institution, all radiologically detected lesions presenting with characteristics that can be reasonably attributed to a malignant process such as atraumatic pain are further investigated with biopsy. Had the biopsy result demonstrated a malignancy, neoadjuvant chemo- and radiation therapy would have been considered with en block resection of the lesion.9 Open biopsy carries increased risks of wound breakdown, haematoma and infection, as well as increasing the risk of tumour seeding along biopsy tracts that are not removed during surgical resection.9 To minimize the risks of biopsy tract seeding, biopsy approach should coincide with the planned surgical incision site such that the tract is easily removed during any future surgical intervention.10 Occasionally, it can be difficult for the radiologist to obtain an appropriate tumour sample for diagnosis when limiting the biopsy approach to the surgical incision plane.10 At our institution, such difficult cases are always discussed with the multidisciplinary team.To our knowledge, intramedullary seeding of a benign cartilaginous tumour, as seen in this case, has not been reported in the literature, although seeding of sarcoma following core needle biopsy is a rare but recognized complication.7 Recently, UyBico et al11 reviewed 363 cases of percutaneous musculoskeletal tumour biopsies and found no instances of needle tract seeding, suggesting that concern for iatrogenic seeding of musculoskeletal tumours may be more widespread than the evidence base to support it.Despite the first reported case of musculoskeletal tumour biopsy tract seeding in 1993, exact rates of occurrence are not yet clear.In view of the findings of our case and that of other cases of musculoskeletal tumour tract seeding, it may be appropriate that short-term post-biopsy imaging be performed to assess for evidence of biopsy tract seeding prior to definitive therapy, in instances where anatomic compartment breach may have occurred, whether histology yields a malignant or benign proliferative process such as chondroid tumour.Distinguishing periosteal chondroma from chondrosarcoma is challenging, as there is significant overlap of symptoms, imaging and histological features.Lesion size is a good differentiator between periosteal chondroma and periosteal chondrosarcoma: lesions less than 3 cm in size are likely to be benign, whereas lesions greater than 7 cm are likely to be malignant.Both benign and malignant cartilaginous lesions can breach extra-anatomical compartments following iatrogenic trauma, including biopsy, the approach of which should be confirmed with the treating tumour service.Follow-up imaging pafter biopsy of cartilaginous lesions may be appropriate to assess for evidence of seeding in instances where anatomic compartment breach may have occurred, whether or not histology demonstrated a benign or malignant proliferative process.Our institute’s Quality Assurance sub-committee of the Human Research Ethics department has reviewed this case and is agreeable to its publication.


Wound botulism is a potentially lethal condition that can cause paralysis. Its association with black tar heroin is a well‐established fact. It is essential to alert clinicians in recognizing the patients with history of injection drug abuse presenting with clinical features of botulism early on admission for prompt diagnosis and treatment. We present 2 cases (48‐year‐old Hispanic Man & 34‐year‐old Hispanic Woman) both with past medical history of heroin abuse was brought to the emergency department with acute respiratory failure, proximal muscle weakness of upper and lower extremity, neck flexor muscle weakness, and diplopia. Urine drug was consistent with opioids. Multiple areas of visible skin popping, a technique of injecting black tar heroin into extravenous subcutaneous sites are seen on the right and left areas of thigh associated with the development of botulismNone declared.IAQ: involved in manuscript writing; MAQ: involved in critical revision of the manuscript; ARV and DK: involved in patient care.


Myelolipoma are tumors of adrenal glands typically found in the adrenal gland, and are comprised of marrow elements and fat. We report a case of an extra adrenal myelolipoma in a 91-year-old patient, who presented to the emergency department with complaints of abdominal pain and shortness of breath. A CT scan of the abdomen and pelvis revealed a mixed attenuation soft tissue mass with admixed fat located within the mesentery inferior to the body of the stomach. A fine needle aspirate of the mass demonstrated a cellular aspirate with maturing trilineage hematopoiesis and mature adipocytes. This case is being presented due to the rarity of extra adrenal myelolipomas. Myelolipomas are uncommon, benign, tumor-like lesions of adrenal gland composed of mature adipose tissue admixed with hematopoietic tissue. They constitute 7-15% of adrenal masses. The incidence of extra-adrenal myelolipoma is rare and accounts for 14% of all myelolipomas . These aA 91-year-old male presented to the emergency department with chief complaints of abdominal pain and shortness of breath. The patient was intubated and placed on mechanical ventilation. A percutaneous feeding tube was also placed for nutritional management. The initial labs showed hemoglobin (Hb): 7.7 gm/dl of blood (N: 12-15.4 g/dl), platelet count: 100,000/microliter of blood  and white blood cell count (WBC): 7200/cubic millimeter of blood . Cultures obtained from blood, urine and sputum were negative for bacteria. Cultures from lower respiratory tract showed normal respiratory flora along with candida albicans. Electrocardiogram (EKG) showed sinus rhythm with marked sinus arrhythmia and 1st degree AV block.Chest X-ray showed bilateral pleural effusions along with consolidation at the base of left lung and cardiomegaly. The CT scan of abdomen and pelvis revealed a 10.0 x 9.7 x 13.0 mixed attenuation mass containing soft tissue and fatty components in the mesentery inferior to the body of stomach  and admixed fat Figure .No bone was identified. CD20 and CD3 highlight small B and T lymphocytes in usual proportions Figures -5.CD34 highlights endothelial cells Figure .CD138 highlights plasma cells, comprising nearly 5% of total cellularity Figure .Cytokeratin stain (MCK) was negative Figure .Flow cytometry performed on the fine needle aspiration of the abdominal mass was negative for a monoclonal B-cell population, aberrant T-cell population, or blasts cells. Lymphoma, carcinoma and myeloid sarcoma were ruled out by flow cytometry and morphologic/immunohistochemical evaluation. The findings were compatible with myelolipoma.Myelolipoma is an uncommon benign tumor, which consists of mature adipose tissue and hematopoietic elements. The most common location is the adrenal gland and extra adrenal myelolipomas are very rare. According to the literature search only less than 50 cases have been reported. The reported sites include liver, spleen, kidney, stomach, mediastinum and pre-sacral area ,7.The pathogenesis of extra adrenal myelolipomas are uncertain; although, they may result from ectopic adrenal rests or hematopoietic stem cells that are stimulated due to endocrine abnormalities ,9. A stuMyelolipomas are usually an incidental finding in patients evaluated for unrelated symptoms. However, patients may present with abdominal pain, which possibly results from tumor infarction, peritumoral hemorrhage or mechanical compression from the tumor .On radiology, myelolipoma usually appear as well-circumscribed masses with a heterogeneous appearance due to the presence of varying amount of admixed fat. CT is the favored imaging technique, which displays focal fatty density. MRI can be used to visualize macroscopic fat. Fat tissue displays high signal intensity on T1-weighted images while the myeloid component shows T2-weighted signal. Fat tissue displays low attenuation on CT imaging . Adrenal myelolipomas may be followed radiographically and no intervention is needed. Extra adrenal myelolipomas are far less common, are often not in the radiographic differential and are more often biopsied.Grossly, extra adrenal myelolipomas can range in size from a few centimeters up to 27 cm . They arMicroscopically, they have a mixture of fatty component and hematopoietic component. They may have a conspicuous lymphocytic population. Megakaryocytes are a diagnostic clue. Myelolipomas do not have bone spicules or sinusoids except in the cases with osseous metaplasia.Liposarcoma is the most common differential diagnosis of myelolipoma. It occurs in the 6th decade of life and can exceed 20 cm in diameter. It appears as a well-circumscribed lobulated mass. The color varies from yellow to white depending on fibrous, adipocytic and myxoid areas . HistoloExtramedullary hematopoietic tumors such as myeloid sarcoma, plasmacytomas, mast cell tumors, etc. are in differential with myelolipomas . They tyAngiomyolipoma are also in the differential diagnosis of myelolipoma. They are typically renal tumors with thickened and hyalinized blood vessels, spindle cells and fat. They are characteristically positive for HMB-45 and negative for S100 .Teratomas are also in the differential diagnosis of myelolipoma. They show tissue from all the three germ layers. They have been reported in the retroperitoneum and can be reliably differentiated from myelolipoma on radiology. Mature teratomas typically present as complex masses with a well-circumscribed fluid component, adipose tissue, sebum and calcification that can be identified on imaging . Our casExtra adrenal myelolipomas may enlarge and bleed; however they are typically stable and surgical excision is only required when they enlarge and symptoms ensue . The lonExtra-adrenal myelolipomas are extremely rare and often discovered incidentally by radiology. Biopsy and histologic examination is essential for diagnosis to differentiate myelolipomas from other benign and malignant lesions. Our patient had a unique presentation of a large extra adrenal myelolipoma presenting in the upper abdomen, which was discovered incidentally and unsuspected by radiology.


Inverted papilloma is an uncommon benign epithelial tumor that typically affects the nasal cavity and originates from the lateral sinonasal wall. Inverted papilloma occurring in the middle ear is an even more rare and aggressive condition. We describe a case of a 76-year-old man who was treated for isolated sinonasal inverted papilloma and after 20 months he was found to have a recurrence in the nasal cavity with middle ear involvement and malignant changes consistent with nonkeratinizing squamous cell carcinoma arising from inverted papilloma. Several surgical procedures were required to remove the tumor along with radiation therapy postoperatively. Sinonasal schneiderian papilloma is a benign neoplastic proliferation that originates from epithelial cells. Inverted papilloma (IP) compromises about 7% of all types of primary tumors occurring in the nasal cavity. These tumors have been reported to be locally aggressive with a high tendency of malignant transformation and recurrence particularly if incompletely resected. The occurrence of IP in the middle ear or mastoid process is a rare entity ,2. We haIn April 2016, a 76-year-old man presented to the ear, nose & throat (ENT) clinic with a four-month history of nasal obstruction and loss of smell, on the left more than the right. There was no history of epistaxis, hearing loss, vertigo or otalgia. The ear canal, tympanic membrane and tuning fork testing was normal. On nasal endoscopy a polypoidal mass filling the left nasal cavity and extending to the right side through the nasopharynx was evident. Pathology was consistent with inverted papilloma. The remainder of the physical examination of the head and neck showed no abnormalities. Computed tomography at that time showed a locally advanced tumor of the left nasal cavity and left maxillary sinus; the temporal bone was clear  normal middle ear pressure and low compliance, as for the left ear it revealed flat (type B) tympanogram. Audiometry results for the right ear showed moderate sensorineural hearing loss with 48 dB pure tone average, as for the left ear results revealed severe mixed hearing loss with a pure tone average of 83 dB with an air-bone gap of 20-25 dBHL from 500 Hz to 4 KHz. Nasal endoscopy showed a small nasal mass limited to the anterior maxillary wall on the left side with an unremarkable nasopharyngeal exam. Computed tomography of the head and sinuses demonstrated complete opacification of the left middle ear cavity and mastoid air cells without evidence of erosive bony changes  due to residual malignant tumor in the left external auditory canal that was detected by positron emission tomography scan (PET) which showed interval progression of the fluorodeoxyglucose (FDG) avid soft-tissue attenuation that involves the left external auditory meatus Figure  and magnThe patient received a total dose of 66 Gy of radiation to the left ear and completed the course of treatment over seven weeks.Schneiderian papilloma or inverted papilloma (IP) are rare benign tumors of epithelial origin. Middle ear inverted papilloma is extremely rare with 13 cases reported so far (Table This report describes a rare case of inverted papilloma of the sinonasal cavity with middle ear involvement. Investigations revealed malignant transformation and positive HPV association. Reported cases of middle ear papilloma reveal higher recurrence rates and malignancy potential compared to those confined to the sinonasal cavity. Accordingly, an aggressive approach to the management of similar lesions is recommended along with strict close follow-up using nasal endoscopy, otoscopy and MRI to detect any recurrence.