The leading cause of diaphragmatic rupture is penetrating abdominal trauma, including gunshot- and stab-related wounds; however, diaphragmatic rupture can also result from blunt trauma to the abdomen. The diagnosis can be difficult to make as the physical examination may be unremarkable, and imaging, that is, a conventional chest X-ray and/or CT imaging, may initially fail to reveal the injury. Failure to recognize diaphragmatic rupture can result in a delayed presentation, sometimes years later, with a potential catastrophic outcome. Therefore, prompt and swift diagnosis is critical to avoid this potential harmful scenario. Traditionally, repair is performed through a laparotomy or a thoracotomy incision. Owing to the many advances made in minimally invasive surgery, not only has laparoscopy become the modality of choice to diagnose diaphragmatic rupture due to its high degree of sensitivity and specificity, but it can provide simultaneous therapeutic intervention as well. We report a case of laparoscopic repair of a diaphragmatic rupture in a 22-year-old female who sustained blunt abdominal trauma during a motor vehicle accident. Diaphragmatic rupture is a rare sequelae following blunt abdominal trauma. A patient can present with a range of symptoms from a completely asymptomatic state to having severe respiratory distress. However, respiratory distress, in and of itself, can be a nonspecific presenting symptom in many other traumatic scenarios. Therefore, a high index of suspicion is necessary to make a diagnosis of diaphragmatic rupture, especially in the absence of pathognomonic radiographic findings. Although diagnostic modalities to detect diaphragmatic rupture, such as multidetector CT imaging, with a sensitivity and specificity of 61–87% and 72–100%, respectively [A 22-year-old female presented to the emergency room after a motor vehicle accident complaining of abdominal and left leg pain, with a pain level described as 8/10. She was a belted, backseat passenger when the car was struck broadside. Airbags were deployed. She denied any loss of consciousness. Chest and cardiovascular examinations were unremarkable; however, she was mildly tender to deep palpation of the abdomen and could not move the left lower extremity due to pain in the left pelvis. Her work-up included a chest X-ray and CT scan of the chest, abdomen, and pelvis that revealed left lung contusion with herniation of the stomach into the left hemithorax Figures 1. Aside fThe patient was taken to the operating room after adequate resuscitation, with a nasogastric tube already in place. The patient was intubated using a single-lumen endotracheal tube as the double-lumen tube was deemed unnecessary by the anesthesiologist. Exploratory laparoscopy was performed. Herniated bowel through a 9 cm posterior left diaphragmatic defect contained most of the stomach, loops of small bowel, and the transverse colon Figures  and 5. WThough penetrating and blunt trauma to the abdomen can both result in diaphragmatic rupture, penetrating abdominal trauma is the leading cause, accounting for 75% of cases . The majThe diagnosis, however, can be difficult because the physical examination may be unremarkable, and 30–50% of diaphragmatic ruptures are missed on initial imaging . TherefoRepair of diaphragmatic rupture has been performed through a laparotomy or a thoracotomy incision for many years. However, open surgical procedures are associated with increased postoperative pain, increased hospital length of stay, and development of long-term complications, such as an incisional hernia , 10. In Diaphragmatic rupture as a result of blunt abdominal trauma is not only uncommon but also potentially underdiagnosed. In the event that there is a scarcity of indicative symptoms and radiographic findings, one must circumnavigate these limitations to reach the appropriate diagnosis. Laparoscopy is an excellent diagnostic and therapeutic procedure in the setting of suspected diagnostic rupture, with or without herniation of abdominal content. It is safe and effective in repairing the diaphragm following rupture due to blunt abdominal trauma.


Inflammatory fibroid polyps (IFPs) are rare mesenchymal lesions that affect the gastrointestinal tract. IFPs are generally considered benign, noninvasive lesions; however, we report a case of an invasive gastric IFP. To the best of our knowledge, this is only the second case report of an invasive gastric IFP.A 62-year-old woman presented with complaints of epigastric pain and vomiting. Computed tomography showed a 27-mm, hyper-enhancing tumor in the prepyloric antrum. Upper endoscopy also showed a submucosal tumor causing subtotal obstruction of the gastric outlet. Because a gastrointestinal stromal tumor was suspected, distal gastrectomy was performed. Histopathological examination revealed spindle cell proliferation in the submucosal layer. The spindle cells had invaded the muscularis propria layer and extended to the subserosal layer. The tumor was finally diagnosed as an IFP based on immunohistochemical findings. No mutations were identified in the platelet-derived growth factor receptor alpha (PDGFRA) gene via molecular genetic analysis.After the discovery that IFPs often harbor PDGFRA mutations, these growths have been considered neoplastic lesions rather than reactive lesions. Based on the present case, IFPs might be considered not only neoplastic but also potentially invasive lesions. Inflammatory fibroid polyps (IFPs) are rare mesenchymal lesions that affect the gastrointestinal tract. Histologically, spindle cells proliferate in the submucosal layer, and they rarely invade the muscularis propria , 2. For 3 (67.5% neutrophils and 0.8% eosinophils), a hemoglobin level of 12.6 mg/dl, and a platelet count of 275,000/mm3. Other blood biochemistry data were normal. Serum anti-Helicobacter pylori (H. pylori) immunoglobulin G antibody was negative . Computed tomography (CT) showed a 27-mm, hyper-enhancing tumor in the submucosa of the prepyloric antrum as well as thickening of the muscularis propria layer and a hyper-enhancing lesion in the subserosa (Fig. A 62-year-old woman presented with complaints of epigastric pain and vomiting for a few weeks. She had a history of traffic trauma followed by a brain abscess and had also undergone a total hysterectomy for a uterine myoma. She was given an antiepileptic agent, a non-steroidal anti-inflammatory drug and a proton pump inhibitor at a local hospital. She had no history of smoking or alcohol consumption. On physical examination, her blood pressure was 123/65 mmHg, her temperature 36.8 °C, her respiratory rate 18/min, and her heart rate 56 beats per minute. There was epigastric tenderness on palpation. Laboratory results indicated a white blood cell count of 7090/mmosa Fig. . The tumosa Fig. . The tumosa Fig. . There wosa Fig. . RegionaIFPs were first described as eosinophilic submucosal granulomas by Vanek in 1949 , and aftH. pylori support this hypothesis [H. pylori is difficult to ascertain. In 2008, Schildhaus et al. identified PDGFRA mutations in IFPs; these mutations had previously been detected only in GISTs [At least 1000 IFPs have been described thus far in the literature, and their etiology has been widely discussed . Originapothesis . Howeverin GISTs . The prein GISTs . In 2012in GISTs . In the Although IFPs are generally considered benign, noninvasive lesions , 2, few In conclusion, we present a second case report of an invasive gastric IFP. Based on the present case, IFPs might be considered not only neoplastic but also potentially invasive lesions. If the invasive characteristics of IFPs are observed in further larger studies, the treatment strategy should be carefully considered to avoid inadequate treatment.


Lesions in the floor of the mouth can be a challenging diagnosis due to the variety of pathological conditions that might be found in this area. Within a broad range of lesions, attention has to be addressed to those that require specific management, such as a dermoid cyst (DC) and a ranula. Especially in pediatric patients, in whom the failure of diagnosis can postpone the correct treatment and cause sequelae later in life. DC, a developmental anomaly, is managed primarily by surgical resection. On the other hand, ranula is a pseudocyst that may be treated by marsupialization. This article reports a large and painful lesion in the floor of the mouth in a pediatric patient. With a diagnostic hypothesis of ranula, two surgical interventions were performed, but there were recurrences of the lesion. Subsequently, the patient was referred to the Oral and Maxillofacial Surgery Unit for re-evaluation. Computed tomography showed a semi-transparent image suggesting a cystic formation. Another surgical procedure was performed where the lesion was completely removed. Anatomopathological analysis confirmed the diagnosis of DC. The five-year follow-up showed no signs of recurrence. This article indicates that although DC in the floor of the mouth is rare, it should be considered in the differential diagnosis of other diseases in this area. This precaution may be particularly important in the following circumstances: 1) Similar lesions that have different therapeutic approaches and, 2) To prevent future sequelae in pediatric patients. Furthermore, lesions that are clinically similar may have diverse etiologies and require specific treatments . These lesions might affect critical functions, such as swallowing and breathingRana species). Furthermore, an inflammatory reaction spreads out to the surrounding stroma,,,Ranula, a pseudocyst, is the result of the extravasation of salivary secretion into the connective tissues after trauma or infection of the sublingual gland. This pathology is characterized by unilateral blue to translucent swelling in the floor of the mouth, which resembles the belly of a frog , with a large, painful, dysfunctional, yellow-coloured, right-sided sublingual mass. Medical history revealed several visits to the outpatient services due to pain and edema intra and extraoral in the affected region. Between ages 9 and 12, the patient had undergone two surgical interventions under local and general anesthesia for the treatment of this lesion. The diagnostic hypothesis was a ranula, and two marsupializations were performed. There were no records of imaging or histopathological exams (pre- or post-operatively), and there was no history of systemic diseases. By means of intra-oral bidigital palpation, a soft, depressible, tender, yellow mass was evidenced and surrounded by adhesions . There w,,,,-,,-Lesions in the floor of the mouth  may have significant symptoms such as dyspnea, dysphagia, and dysphonia,There is a probability that the patient had a DC that was misdiagnosed and treated as a ranula. Consequently, inappropriate surgical procedure  was performed, and the treatment failed. On the other hand, this case report raises the possibility that those two lesions (DC and ranula) could be present concomitantly and the previous treatments only were able to eradicate the ranula, leaving the DC in the region. In this case, the lack of a detailed clinical investigation (e.g. imaging exams) would be the reason for the non-identification of the DC. An additional factor that might contribute to the failure of diagnosis\treatment was the position of the lesion. Usually, DC is found in the middle line of the body and ranula is unilateralIn summary, in the presence of lesions that might have several diagnostic hypotheses, a comprehensive clinical assessment has to be made. This may include complementary exams such as incisional biopsies, biochemical and imaging tests. Furthermore, biological material collected during the surgical procedure has to be sent to anatomopathological examination. These clinical procedures are of particular importance when lesions of similar clinical features  have different treatment indications. The misdiagnosis can lead to an inefficient outcome of the therapy and recurrence of the lesion. In children, surgical treatment failures may involve multiple therapeutic procedures that can cause emotional problems, social isolation, and alteration in the development of the face.


We describe a case of a 53 years old patient who underwent right nephrectomy for a renal tumor in 2005. The histological examination revealed an hemangiopericytoma with graveness signs. Ten years later, the patient developed a huge abdominal mass. CT scan showed a voluminous locally advanced tumor measuring 30*20 cm. The mass was multilobed and hypervascularized (A) Witch was compatible with a hemangiopericytoma. The biopsy confirmed the recurrence of the hemangiopericytoma (B). The patient received a palliative chemotherapy taking into consideration local and metastatic extension. Hemangiopericytoma is a rare vascular tumor that emerges from Zimmerman perocytes. Usually it’s a voluminous asymptomatic mass with variable malignancy potential, and no specified clinical or radiological aspects. The standard of care is surgery and it should be suggested even for recurrences, the management of locally advanced and metastatic disease consists on palliative chemotherapy for sarcoma and should be discussed in a pluridisciplinary reunion.


Patent vitellointestinal duct (PVID) is a benign congrnital anomaly ususally presenting with fecal discharge from the umbilicus. In this report, we describe two cases of PVID presented with massive bowel prolapse through the PVID and signs of intestinal obstruction. Surgery revealed prolapse of the ileal intussusceptum through the PVID. Both of the babies were sucssesfully managed with surgery.  Case 1: A full term, first born, male baby presented to us at day 20 of life with some feculent discharge from his umbilicus for ten days. The umbilicus revealing a red prolapsing mass and there was a small quantity of faecal discharge. Examination showed a soft, distended abdomen with a small tubular mucosal lined structure at the umbilicus . Parents refuted surgical management at that time. At two months of age, the baby presented with bilious vomiting, dehydration, and a bowel mass protruding from the umbilicus . After stabilization, he underwent trans-umbilical exploration. Operative finding were prolapsed ileal intussusceptum through PVID with small segment of compromised ileum. Patient managed with reduction of the prolapsed bowel and primary anastomosis with resection of PVID along with segment of compromised small bowel.. The patient's immediate postoperative period and follow up of up to six months were uneventfull. Histopathological examination of the excised specimen suggestive of small bowel tissue that was consistent with PVID without any evidence of ectopic mucosa. Case 2: A 1.5-month old male baby presented in our emergency with bowel mass protruding from umbilicus, abdominal distention, and vomiting since last six hours . Baby was first born full term with normal antenatal scan. Parents noticed that baby has small red protruding mass at umbilicus with small faecal discharge since day 12 of life. Baby was malnourished with weight 2.2 kg. Baby had no associated anomalies. Baby underwent trans-umbilical exploration with reduction of the prolapsed ileal intussusceptum through PVID and primary anastomosis with resection of PVID along with segment of compromised small bowel were done. . Postoperative course was uneventful.Vitellointestinal duct usually obliterates by the end of the seventh week of gestation. Persistence of this gives rise to a spectrum of congenital anomalies - sinus, cyst, fistula, band, Meckels diverticulum. The incidence of PVID is 0.0053%.[1] PVID seen eight times more common in males and mostly present at neonatal periods as our both cases are male.[2] The presentation is with fecal discharge from umbilicus through a mucosal lined tubulr structure. It is a benigh condition with very straightforward surgical treatment . Delay in treatment can cause bleeding and mucosal prolapse through PVID. Massive prolapse can occur leading to intestinal obstruction. Massive prolapse through narrowed umbilical ring also obliterates bowel lumen leading to mechanical bowel obstruction. In severe cases of massive mucosal prolapse, bowel ischemia may ensue thus necessitating bowel resection and anastomsois.[3] Only few of the previous reported cases prolapsed intussuscepted distal small bowel via patent vitellointestinal duct were found. [1-5] Factors responsible for prolapsed of bowel may be wide weak umbilical defect, condition that cause increase intraabdominal pressure along with partial bowel obstruction at PVID sites. In view of these serious consequences, PVID should be treated promptly. To conclude, the presentation of PVID may be varied form minor skin excoriations to lethal bowel obstruction and strangulations. Cases needing early surgical correction should be identified and corrected promptly.Source of Support: NilConflict of Interest: None declared


Osseous metaplasia is a rare finding in colonic neoplasms. We report a case osseous metaplasia in a 74 year-old male who underwent surveillance colonoscopy and found to have a 7 mm rectal polyp. Histopathologic examination revealed an inflammatory polyp with osseous metaplasia. Osseous metaplasia is a phenomenon described in a wide variety of tissue types in relation to both neoplastic and non-neoplastic conditions. In the setting of neoplasia it is seen in both benign and malignant lesions. The mechanism responsible for this metaplastic change is not completely understood, and its impetus remains unidentified. Furthermore, osseous metaplasia is exceedingly rare in colon polyps. Individual cases have been reported, often with accompanying literature reviews, describing the phenomenon and theories regarding potential pathogenesis. In these literature reviews, it seems that several cases are often overlooked, most citing 5 - 10 cases total. We report a case of osseous metaplasia in an inflammatory rectal polyp with an accompanying literature review, summary of seventeen previously reported cases of osseous metaplasia in a variety of colon polyps, and a novel proposed mechanism for its pathogenesis.A 74 year-old male with history of prior tubular adenoma of the ascending colon removed via snare polypectomy, hyperlipidemia, coronary artery disease status post angioplasty with stent placement, prior traumatic left frontotemporal subdural hematoma status post evacuation, urethral stricture status post multiple dilatations with recurrent urinary tract infections, and an anucleate right eye secondary to childhood trauma presented for a surveillance colonoscopy. At colonoscopy, a 7 mm rectal polyp was discovered which was removed by cold snare .On pathologic gross examination, the polyp was a 1.0 x 0.4 x 0.4 cm fragment of tan-red mucosal tissue that was bisected and submitted for histologic examination. Microscopically, H&E stained sections of the polyp showed fragments of denuded colonic mucosa with an edematous and congested lamina propria, overlying fibrinopurulent debris, and adjacent granulation tissue . Within Osseous metaplasia is rarely encountered in colon polyps. Seventeen cases have been reported in the reviewed literature .Of the pOsseous metaplasia is a well-described phenomenon, but it is extremely rare. A review of cases at an academic medical center over a 10 year period revealed 85 cases of heterotopic ossification out of 125,000 surgical pathology specimens. Twenty-two of the cases were neoplastic lesions, and the remaining 73 were non-neoplastic . OsseousCurrent evidence points toward the differentiation of mesenchymal cells into osteoblasts, which subsequently produce bone. Immunohistochemical (IHC) analysis of tissue with osseous metaplasia, by Randall et al in 1989, demonstrated alkaline phosphatase expression, a marker of synthesis, in the osteoblast-like cells of metaplastic bone and to a lesser degree in the glandular cells of metastatic colonic adenocarcinoma and adjacent proliferating mesenchymal cells . More rein vivo mechanics of osseous metaplasia are still under investigation, the initial step down the path of osteoblastic differentiation is still unknown. Perhaps shedding some light on the subject, in in vitro studies, mouse fibroblasts cultures under the influence of a four specific transcription factors  have generated pluripotent stem cells. Subsequently these stem cells have demonstrated the capability to differentiate into cell types from all three germ cell layers [in vitro, has demonstrated a similar phenomenon [Though the l layers , 26. Addenomenon . Perhaps


A 46 years old man, complaining about abdominal pain, was submmited to a magnetic resonance having a giant liver hemangioma as an incidental finding . In the Hemangioma is the most commonly benign tumor found in the liver with a prevalence between 0.4% to 20%. These lesions have definitive diagnosis by cross-section methods (computed tomography and magnetic resonance imaging), because they present characteristic imaging findings of progressive and discontinued peripheral globuliform enhancement, in addition to high signal on T2-weighted sequences on magnetic resonance imaging. However, atypical liver hemangiomas are difficult to diagnose, and they are caused by complications such as thrombosis, heart failure, hemorrhage, or previous typical sclerosed hemangioma.1(-) These cases can be mistaken with other lesions, such as intrahepatic cholangiocarcinoma, hepatocellular carcinoma or metastasis. Presumptive diagnosis is only possible when previous exams shows temporal evolution of a typical hemangioma.Hyalinized hemangioma can present change in enhancement pattern and characteristic signal, in addition to contour retraction.-5 Th


In birds there are reports of intracranial lesions but not of the clinical, computed tomographic and histopathologic features of acute intraparenchymal cerebral haemorrhage in Iberian golden eagle.(Aquila chrysaetos homeyeri) with no history of trauma, presented with acute opisthotonus, left head tilt and circling, anisocoria, positional nystagmus, and ataxia. The main differential diagnosis were hypovitaminosis B or E and intracranial disease due to trauma, infection, toxins or masses. A computed tomography (CT) of the head was performed with an 8-slices scanner and evidenced a hyperdense (63–65 HU) non-enhancing homogeneous well delineated round area in the midbrain, with 6 mm in its highest diameter. The attenuation values and the non-enhancing nature of the lesion strongly suggested the diagnosis of acute intraparenchymal haemorrhage, which was histologically confirmed after necropsy.The following report describes a case of a 30-year-old Iberian golden eagle In birds with a central neurological dysfunction, the diagnosis of acute brain haemorrhage should be considered when the CT evidences a non-enhancing, homogeneous, well circumscribed hyperattenuated round area. Aquila chrysaetos homeyeri) is a subspecies of the golden eagle that inhabits the Iberian Peninsula. It has slight variations than in the form Aquila chrysaetos chrysaetos of northern Europe, namely smaller size and darker coloration, with less marked shades. The golden eagle lives preferentially in mountainous areas, but it is not uncommon in places of low altitude or depopulated [The Iberian golden eagle  from a zoo in the region of Porto-Portugal, was presented with disorientation, acute opisthotonus, left head tilt and circling, anisocoria, positional nystagmus, and inability to fly and stand. There was no known history of trauma and no external lesions were visible. The animal was placed in a warm, oxygenated incubator with intravenous fluid therapy (ringer lactate 120 ml/kg/daily in bolus), meloxicam (0.2 mg/kg/daily subcutaneous injection), itraconazol  and enrofloxacin . The main differential diagnosis considered were hypovitaminosis B or E and intracranial disease due to trauma, infection , toxins or cerebral mass .A 30-year-old Iberian golden eagle , the golden eagle was transported to the Small Animal Veterinary Hospital of the University of Porto (UPVet) in order to perform a computed tomography of the head with an 8-slices scanner . The animal was anesthetized with isofluorane, positioned in sternal recumbency and taped to the CT table. Axial images were acquired with a helical scanning mode at 200 mA, 120 Kv, 0.6 mm slice thickness and using soft tissue and bone reconstruction algorithms, before and after intravenous injection of iodinated contrast medium (250 mg I/Kg) administered into the basilic vein. Dorsal and sagittal reconstructions were also obtained from transverse images. CT scans showed a cataract in the left eye and a hyperattenuated non-enhancing homogeneous well delineated round area, ventral to the third ventricle, with a density of 63 to 65 HU and 6 mm in its highest diameter (6 × 4.4 × 5.4 mm). This lesion did not produce deviation of the One day after the CT scan the eagle was euthanized for humanitarian reasons and the brain was removed and dissected after fixation with 10% formalin. Post-mortem examination revealed the presence of a focal area of black tissues in the parenchyma of the midbrain, consistent with haemorrhage Fig. . Brain sIn birds, besides trauma, other differential diagnoses for central nervous system dysfunction include infectious diseases , nutritional imbalances, toxins , neoplasia, congenital abnormalities and cardiovascular, hepatic and renal disorders .The assessment of the neurological bird should include a thorough history, a detailed external physical examination, haematology and serum biochemistry, radiography, ultrasonography and endoscopy. Additional diagnostic tests such as heavy metal analysis, serology/PCR for infectious diseases and cerebral spinal fluid analysis may be required in some clinical cases . AlthougDiagnostic imaging procedures such as radiology, computed tomography and magnetic resonance imaging (MRI) are extremely useful to evaluate the severity of the head injury, namely to identify fractures and the presence of bleeding. These diagnostic tools also help in determining the presence of foreign bodies, congenital abnormalities and masses such as granuloma, hematoma, abscess or neoplasia .As previously mentioned, in this clinical case there was strong evidence of a central nervous system disorder so, considering that clinical neurological signs are rarely pathognomonic , a multiHaliaeetus leucocephalus). In the previous study, one animal presented a multifocal acute intraparenchymal haemorrhage [Psittacus erithacus), but no abnormalities were observed in the CT scans [Although there are no publications describing the computed tomographic characteristics of acute intraparenchymal haemorrhage in raptors, CT has been used successfully to locate intracranial lesions in birds with a reported sensitivity of 80% , 14. MRImorrhage . AdditioCT scans .The CT image of the lesion described in this case report evidenced attenuation values around 63–65 HU which are within the limits recognized for acute haemorrhage (60–80 HU) , 17. AddIn humans, dogs and cats, considerable controversy exists concerning what constitutes appropriate therapy for severe brain-injured patients. However, it is commonly accepted that is essential to alleviate brain swelling and prevent damage to vital brain-steam structures. The ultimate goal is to return the patient to the role in society occupied prior to the injury . In birdAquila chrysaetos homeyeri. In raptors with a central neurological dysfunction, the diagnosis of acute intraparenchymal haemorrhage should be considered when the CT evidences a non-enhancing, homogeneous, well circumscribed hyperattenuated round area.This case report contributes for the imaging characterization of intracranial disease and normal CT anatomy in wild animals, namely in


Ectopic ureteroceles are one of the most common human urinary tract anomalies. They tend to be recognized and treated in early childhood, especially when they have prolapsed. In most cases surgical therapy is inevitable. In this case report, however, we present the unusual case of a 26-year-old woman suffering from a prolapsed cecoureterocele without any known history of an ectopic ureterocele so far. She was successfully treated without the need for a surgical procedure. With an incidence of 1/5000 to 1/12000 per birth, ureteroceles belong to the most common urinary tract anomalies in humans  or anothA 26-year-old woman admitted herself for urological consultation to our hospital. She described a recent history of gross haematuria as well as having recognized a prolapsing vaginal mass. After our first examination we presumed the vaginal mass to be a thrombosed urethral caruncle. The initial sonographic evaluation of both kidneys revealed no pelvic dilatation. While the first try of carefully repositioning our clinical findings  was unsuDuring the examination in general anesthesia we found that some clear fluid was secreted from the circular prolapsed vaginal mass when putting pressure on it. Upon further pressure the mass retreated itself spontaneously into the outer urethral meatus. As will be seen in The right-sided ureteral ostium showed some small protrusion as well, presumably coinciding with another small ureterocele on this side. The further cystoscopy was largely inconspicuous so that we decided to end the procedure due to the now resolved acute situation which, nonetheless, required further investigation.In order to confirm our intraoperatively newly obtained diagnosis of a prolapsed ureterocele, we did a CT scan of the patient's abdomen the day after the surgical intervention. In the CT scan  the presWhile being clinically asymptomatic and with the renal retention parameters being always within normal range, the patient was then discharged from hospital and followed up one month later. In the follow-up examination there was no sonographic incidence for a dilated renal pelvis on both sides and in cystoscopy the left-sided ureterocele seemed to have regressed in size. Even the ureteral ostium was now easily identified.We established two further follow-up appointments 5 and 12 months after the initial consultation. In both cases the patient was found to be absolutely asymptomatic. No further episodes of gross haematuria or urinary tract infections were reported. Sonography always showed normal conditions concerning the renal drainage and sonography as well as cystoscopy during the 5- and 12-month follow-ups revealed a further regression of the ureterocele in size. The sonographic findings of the 12-month follow-up are to be seen in Figures Since a prolapsed cecoureterocele, especially in adults, is a highly rare condition, it is rather difficult to give an evidence-based recommendation upon its treatment. The primary goal however should always be the prevention of complications such as loss of renal function, recurrent urinary tract infections, and urinary incontinence . Due to In cases of blindly ending ureters, hypoplastic renal segments, which are drained by the ectopic ureter, or infrasphincteric ureteral orifices, a surgical approach such as heminephrectomy and ureterectomy is largely considered to be the first-line therapy , 5. AnotStill our patient was asymptomatic in all follow-up examinations so far, without having ever undergone any surgical intervention except the repositioning of the ureterocele in anesthesia. We therefore suggest that cases of cecoureterocele in adults, which have been asymptomatic in their lives so far, should, after ruling out any complicating circumstances, be treated conservatively in the first place. Close-meshed follow-ups have to be established nonetheless, in order to be able to surgically interfere as soon as there are any complications under the conservative treatment. This strategy is also proposed by the only retrospective study about the topic, which has been published so far . Even wh


External auditory canal cholesteatoma (EACC) is a rare condition with an estimated incidence of 1.2 per 1000 new otological patients. It is often mistaken with keratosis obturans. We discuss an extensive primary EACC with an aural polyp in a male which was managed by modified radical mastoidectomy. External auditory canal cholesteatoma (EACC) is a rare condition with an estimated incidence of 1.2 per 1000 new otological patients . EACC isA 30-year-old male presented with complaints of left ear intermittent scanty discharge for 10 years and a decreased left hearing for 1 year.On otoscopic examination, a foul smelling discharge was present along with an aural polyp occluding the EAC opening. Rinne was negative, and Weber was lateralized to the affected ear.High-resolution computed tomography (HRCT) showed homogeneous soft-tissue density, filling the left EAC, extending into the mastoid cavity, destroying the posterior wall of the EAC. Medial bowing of the tympanic membrane could also be seen. Focal bony destruction could be seen in inferior EAC .Pure tone audiometry showed a normal right ear hearing level of 13 dB pantonal and moderate conductive type of hearing loss with 47 dB in the left ear .The patient underwent modified radical mastoidectomy with graft only. The ear examination under the microscope revealed a retracted intact pars tensa and pars flaccida and a polyp arising from the facial ridge and the remnant posterior canal wall. The posterior canal wall was lowered up to the vertical part of the facial ridge by the disease. The cholesteatoma was present in the antrum, periantral, retrofacial, retrolabyrinthine, sinodural angle, tip cells, and around the sinus plate. Granulation tissue was present along the stapes. The facial nerve was dehiscent at the horizontal, 2nd genu, and vertical portion with an intact sheath . MalleusThe three-month follow-up examination showed a healthy cavity.Though cases of the EACC have been reported as early as 1850 by Toynbee  and 1893Tos has classified EACC based on pathogenetic theories into 1) primary EACC, 2) secondary EACC, and (3) cholesteatoma associated with congenital atresia of the ear canal . The aet primary  secondarThere is no gender, age, or side preponderance. Though the most common presenting symptoms reported in the literature are otalgia and otorrhea, patients may present with external ear canal occlusion, hearing loss, itching, or even asymptomatic signs. Secondary cases are usually less extensive than primary or less prominent symptoms . EACC isDifferential diagnosis includes keratosis obturans, postinflammatory medial canal fibrosis, malignant otitis externa, and neoplasms of the EAC. For better differentiation and to determine the true extent of the disease which might be inapparent at clinical examination, imaging is strongly recommended. Temporal bone CT shows EACC as a soft-tissue mass within the EAC, with adjacent bone erosion. Bone fragments may be present within the mass. The cholesteatoma may extend into adjacent structures .Differentiating it from keratosis obturans, hearing loss due to EACC is mostly infrequent; the pain sensation is more dull and less acute than in keratosis obturans . The lesSmall lesions can be treated conservatively or by minimal procedures under local anesthesia, while larger lesions need proper surgery with removal of the cholesteatoma, burring off the affected bone areas, and grafting the defects with fascia. Sometimes even small lesions have to be treated aggressively if resistant to conservative management .External auditory canal cholesteatoma (EACC) is a rare condition which can be easily diagnosed and differentiated radiologically from keratosis obturans and can be managed by modified radical mastoidectomy.


Dendritic fibromyxolipoma is a rare and distinctive soft tissue neoplasm that is considered by many authors as a variant of spindle cell lipoma and characterized by the presence of dendritic cytoplasmic processes, plexiform vascular pattern, and keloidal collagen. It has never been reported in the larynx and hypopharynx. Its rarity and the potential to mistake it as a more clinically aggressive myxoid soft tissue neoplasm highlight the importance of its recognition. Here, a case of a dendritic fibromyxolipoma of the pyriform sinus in a 38-year-old male who presented with dysphagia, change of voice, and stridor is reported. A review of the literature, including histopathologic features and differential diagnosis, is also included. Lipomas are the most common soft tissue tumors in adults. Spindle cell lipoma (SCL) is an uncommon variant that has a characteristic clinical setting. It usually presents as a mass in the posterior neck and shoulder region of men between the ages of 40 and 50. It has also been described in many other locations. About 7 cases have been reported in the larynx and hypopharynx. Dendritic fibromyxolipoma (DFML) is a rare and distinctive tumor that is considered by many as a variant of spindle cell lipoma characterized by extensive myxoid change and the presence of stellate cells with dendritic processes. A total of 21 cases have been reported, none of which are in the larynx and hypopharynx. Here, we describe a case of dendritic fibromyxolipoma of the pyriform sinus, with review of the literature.A 38-year-old male who is known to be a heavy smoker for 10 years presented with progressive dysphagia for one year, associated with change of voice, stridor, and sleep disturbance in the last three months. He has no past history of trauma or surgery in the head and neck and no family history of cancer. Laryngoscopic examination showed a large oval mass originating from the left pyriform sinus and causing narrowing of both the hypopharynx and larynx. The clinical impression was that of a retention cyst.Contrast-enhanced CT scan of the head and neck was performed. It confirmed the presence of the mass in the hypopharynx, measuring 3.4 × 3.4 × 2.8 cm. It was well-defined, hypodense, mostly homogenous, and nonenhancing, with a very focal area of contrast enhancement .2 laser was performed. Gross examination revealed multiple pieces of soft yellow-tan and glistening tissue measuring 7.5 × 6.5 × 0.5 cm in aggregate  or an intermediate form between these two entities , 9. EvidDFML can be confused with other more clinically aggressive neoplasms, including myxoid liposarcoma (MLS), low-grade fibromyxoid sarcoma (LFMS), and myxofibrosarcoma, especially the low-grade type, highlighting the importance of its recognition. MLS typically develops in the deep soft tissues of lower extremities. It shares many features with DFML including plexiform vascular pattern and abundant myxoid matrix. However, the lack of lipoblasts and atypical cells, negativity for S-100 and positivity for CD34, differentiates it from DFML. In addition, about 95% of cases of MLS harbor a recurrent translocation involving DDIT3 gene at chromosome 12 . It showFollow-up data on all available reported cases showed no recurrence or metastases, with periods ranging from 4 months to 13 years.In conclusion, DFML is a rare tumor that shares many similarities with spindle cell lipoma. This study presents the first case reported in the hypopharynx. It is important to be aware of this lesion in order to not misdiagnose it as other clinically more aggressive neoplasms such as myxoid liposarcoma and low-grade fibromyxoid sarcoma. More studies including molecular testing for 13q deletion and NAB2-STAT6 fusion  in cases


We document the rare occurrence of multiple primary benign lesions that can occur in bilateral ovarian masses with benign imaging appearances and tumor markers. In addition, this case report contributes important information that may aid physicians in guiding their patients to make optimal clinical decisions together. A female's lifetime risk of having ovarian tumor is 6.0–7.0% A 35‐year‐old nulligravid woman presented to our gynecology outpatient clinic of the King Fahad Medical City, Saudi Arabia, with gradual distension of the abdomen and discomfort over 1 year. The swelling was accompanied by mild lower abdominal pain, constipation, and poor appetite. There was no history of vomiting or other gastrointestinal symptoms, urinary symptoms, colicky pain, and fainting attacks. She had no previous history of any illnesses, allergies, or operations. She denied the use of any medications. There was no family history of malignancies. Her menarche commenced at the age of 12 years.2. Physical examination demonstrated that there was no jaundice, edema, or lymphadenopathy, and secondary sexual characteristics were evident. Abdominal examination revealed a large ill‐defined pelvic‐abdominal cystic mass extending from the pubis up to the umbilicus with an abdominal girth of 95 cm. There was dullness upon percussion but no tenderness. Upon auscultation, the intestinal sounds were normal. Her external genitalia were normal with no abnormality detected by speculum examination. Bimanual examination revealed a normal‐sized uterus, and a cystic mass was felt bilaterally near the posterior fornix that was approximately 7 cm in diameter.Her body weight was 80 kg, her height was 161 cm, and her BMI was 30.86 kg/mTransabdominal and transvaginal ultrasound were performed, which showed a bilateral pelvic multiloculated cystic mass approximately 13 × 10 cm in the right ovary and 6 × 5 cm in the left ovary, with evidence of solid components and septations. The uterus was normal, and endometrial thickness was 8 mm. CA‐125 was 30IU/mL, and other tumor markers  were within normal ranges. Magnetic resonance imaging (MRI) findings were consistent with bilateral multiloculated cystic ovarian lesions. The cyst on the right side measured 13.6 × 15.4 × 6.8 cm, while that on the left side measured 3.6 × 7.4 × 3.1 cm in the anteroposterior, transverse, and craniocaudal dimensions .Ovarian neoplasms may be divided into four main groups, which include epithelial tumors (65–75%), germ cell tumors (15%), sex‐chord‐stromal tumors (5–10%), and metastatic tumors (10%) The most common complications of benign ovarian cysts are torsion, hemorrhage, and rupture. Small ovarian cysts are usually asymptomatic and may be found incidentally either clinically or on ultrasound. There are many differential diagnoses for ovarian cysts, such as functional cysts, omental cysts, and mesenteric cysts Microscopic features demonstrate that the serous cystadenoma is lined by a flat (one cell layer) ciliated epithelium covering broad fibrous stromal cores with bland ovoid basal nuclei. On the other hand, microscopic features demonstrate that the mucinous cystadenoma has a layer of columnar cells that are endocervical‐like or intestinal‐like, with uniform round or oval basal nuclei and clear or amphophilic cytoplasm‐lined fibrous stroma Most of the bilateral ovarian masses with multiple primary cancers in the literature are malignant in nature We document the rare occurrence of multiple primary benign lesions that can occur in bilateral ovarian masses with benign imaging appearance and tumor marker. In addition, this case report contributes important information that may aid physicians in guiding their patients to make optimal clinical decisions together.SB: literature research, drafting of the manuscript, and corresponding author. HA and AMB: wrote the case description. MA: provided the description of the radiology images. JA: provided the description of the pathology images. AFB: reviewed the literature and involved in writing. DA: critically reviewed and revised the manuscript. All authors read and approved the final manuscript.The authors have nothing to disclose and there was no funding for the study. There are no conflict of interests. The work was not presented at any meeting.


Identifying the etiology of chronic diarrhoea might be challenging in some patients, and before a diagnosis is made these patients may spend a substantial length of time with unresolved symptoms leading to uncertainty and anxiety that is severely impairing their life quality. A 45-year-old female was referred by her general practitioner with a 5-year history of increasingly frequent episodes of cyclical diarrhoea, vomiting, abdominal pain and intermittent palpitations. Contrast CT Abdomen/Pelvis revealed a 36x33x46 mm mass in the aorto caval region of her retro-peritoneum, just above the bifurcation.  On the basis of her symptoms, CT findings and an elevated plasma metanephrine level of 2314pmol/L , it was at this point a likely diagnosis of a phaeochromocytoma was made. The retroperitoneal mass was successfully resected, and the histology confirmed a Phaeochromocytoma. Her symptoms rapidly improved and she made a good recovery. This unusual case highlights some of the dilemmas that arise when investigating patients with chronic and recurrent diarrhoea and vomiting.  Pheochromocytomas are rare and often sporadic tumours of catecholamine-secreting chromaffin cells, usually present within the adrenal medulla, but also may occur elsewhere . Early dA 45-year-old female was referred by her general practitioner with a 5-year history of increasingly frequent episodes of cyclical diarrhoea, vomiting, abdominal pain and intermittent palpitations. Her bowels would open up to ten times a day and she described them as ‘explosive’ and loose in nature.  There was no blood or mucus per rectum, or any nocturnal symptoms. She vomited approximately fifteen times a day and experienced non-specific abdominal pain. These episodes would last for several days and occur on a monthly basis. Other than a Laparoscopic Cholecystectomy, she had no significant medical, surgical or family history, and took no regular medications. The patient’s persistent cyclical symptoms resulted in 7 identical short admissions to hospital, during which she was diagnosed with ‘non-specific abdominal pain’. Each time symptoms settled with conservative therapy, and she was discharged with the reassurance of normal routine bloods and simple abdominal imaging.  During her latest admission, she was found to be hypertensive with a systolic of 160mmHg, which spontaneously resolved prior to discharge, and was not thought to be clinically relevant at the time.Although being actively investigated as an outpatient, the patient requested a second opinion and so a referral was made to the regional tertiary centre. She was thoroughly investigated and returned to Milton Keynes Hospital with a list of possible differential diagnoses including Cyclical Vomiting Syndrome, Bile Salt Malabsorption and Visceral Hypersensitivity. No records of any work up are available. Since the patient had a history of laprascopic cholecystectomy, it was hypothesised that her pain might be explained by a retained gallstone. However, two MRCPs were normal with no retained gallstone or common bile duct dilation was found. Abdominal and pelvic ultrasounds were also normal.  Therefore, the pain was considered to be originating from her renal tract and although the first CT KUB was normal with no evidence of renal calculi or hydronephrosis, a subsequent CT KUB confirmed the peri-aortic lymphadenopathy. This incidental finding prompted a Contrast CT Abdomen/Pelvis in September 2015, which found a 36 x 33 x 46mm mass in the aorto caval region of her retro-peritoneum, just above the bifurcation. While local and regional MDT meetings were being sought, the patient continued to be investigated for a co-existing pathology. Both OGD and Colonoscopy were normal, in addition to blood tests including thyroid function, autoimmune profile, porphyria, CA19-9 and HIV. She demonstrated no evidence of pancreatic insufficiency with a faecal elastase of >500µg/g and TB Elispot negative. The MDT outcome was to biopsy the retroperitoneal mass, but due to the complexity and proximity of the lesion to the aorta, she was referred to the national sarcoma team in Birmingham.  On the basis of her symptoms, CT findings and an elevated plasma metanephrine level of 2314pmol/L , it was at this point a likely diagnosis of a Phaeochromocytoma was made. Furthermore, a meta-iodobenzylguanidine (MIBG) CT was performed and showed that the retroperitoneal aorto caval mass was clearly avid, in keeping with an ectopic Phaeochromocytoma. There was no abnormal activity elsewhere in the abdomen, and particular within the adrenal glands. She was subsequently reviewed by the Endocrinology team who commenced Doxazocin 4mg three times daily in order to control her hypertension, and she was listed for surgery.  Despite a very labile systolic blood pressure, fluctuating between 40-300mmHg, the retroperitoneal mass was successfully resected, and the histology confirmed a Phaeochromocytoma (Para-ganglioma with lymph node metastases (3/9), Ki-67 less than 3%, less than 1/12 HPF mitosis). Her symptoms rapidly improved and she made a good recovery.This unusual case highlights some of the dilemmas that arise when investigating patients with chronic and recurrent diarrhoea and vomiting. It raises the question as to whether we should be routinely screened for Phaeochromocytomas in these cases.1. Nausea, anxiety and diarrhoea may also be experienced. Diagnostic tests include 24-hour urinary and plasma metanephrine, and less frequently, urinary vanillymandelic acid (VMA) levels2. However, increasing numbers are diagnosed incidentally by CT or MRI imaging2. Timely surgical resection with pre-operative optimisation through α/β blockade medication is the treatment of choice, and often results in rapid resolution of symptoms2. If advanced, there is a role for chemotherapy. Pheochromocytomas are rare and often sporadic tumours of catecholamine-secreting chromaffin cells, usually present within the adrenal medulla, but also may occur elsewhere. Through over stimulation of α-/β-adrenoceptors, they classically present with a symptom triad of paroxysmal headaches, tachycardia and sweating3. Benign pheochromocytomas have an excellent prognosis with a 5-year survival rate greater than 95%, but require lifelong follow-up due to disease recurrence, especially with large tumours (>50mm)Phaeochromocytomas are extremely rare, however as this case demonstrates, they should be included within the differential diagnosis for patients with recurrent episodes of diarrhoea and vomiting.


Ectopic hepatocellular carcinoma (HCC) is a rare disease that mostly originates from an ectopic liver.The patient was admitted with upper abdominal distention for 3 months, which aggravated after meal.A contrast-enhanced computed tomography (CT) scan revealed multiple abdominal masses. After exploratory laparotomy and histological examination, the patient was diagnosed as ectopic HCC.Exploratory laparotomy was performed for the purpose of diagnosis and treatment.The tumors were excised by surgery and his symptom of upper abdominal distention was disappeared. A second surgery was performed for tumor recurrence and the patient died with total survival time of 22 months.Ectopic HCC was usually in clinically silent, unless compression symptoms or intra-abdominal bleeding appeared. It did not have any typical character features in CT or Magnetic resonance imaging, may present with multiple abdominal masses. Surgery resection seems to be one of the effective treatments for ectopic HCC, though it is detected with multiple tumors. We report a case of ectopic HCC manifesting multiple abdominal masses located in different positions. To the best of our knowledge, there have not any similar cases reported before.Ectopic hepatocellular carcinoma (HCC) is defined as HCC arising from hepatic parenchyma located in an extrahepatic organ or tissue. It mostly originates from an ectopic liver that is considered as a rare developmental error due to early or late developmental anomalies from hepatic tissue migrating aberrantly within the septum transversum or onto the pars cystic.2A 56-year-old man was admitted to our hospital for further evaluation of multiple abdominal masses. He had felt upper abdominal distention for 3 months, which aggravated after meal. There were no other associated symptoms. The patient was a chronic smoker without any other special hobbies, and denied hepatitis. Informed consent for study was obtained from the patient.Physical examination found nothing unusual. The laboratory tests, including complete blood count and liver function, were almost in the normal range. Hepatitis B virus surface antigen (HBs Ag) and hepatitis C virus antibody (HCV Ab) were seronegative, hepatitis B virus surface antibody (HBs Ab) was positive, hepatitis B virus DNA was <1000 copies/mL. Serum level of carbohydrate antigen 125 (CA-125) and carcinoembryonic antigen (CEA) were slightly elevated , and the serum alpha-fetoprotein (AFP) was in the normal level (8.03 ng/mL).A contrast-enhanced computed tomography (CT) scan revealed multiple masses located in left upper quadrant, hepatogastric gap, right abdomen, and excavatiorectovesicalis with irregular margin, heterogeneous density, and significant enhancement. The spleen, bladder, prostate, and liver capsule were seemed to be involved Fig. A–C. MagnExploratory laparotomy was performed for the purpose of diagnosis and treatment. Intraoperatively, a giant irregular friable mass was located in upper abdomen, measured 30 cm × 20 cm × 15 cm, adhered to the spleen, omentum, and left diaphragm, blood supplied by vessel derived from splenic vessel, and no connection was identified between the tumor and the edge of the left hepatic lobe. Another mass was in pelvic cavity, 20 cm × 15 cm × 10 cm in size, had no adhesions to connective tissues  case; the liver was cirrhotic in only 6 of 22 cases (27%). Thus, we speculate that the virus infection, whose role was emphasized in the sequence viral hepatitis → liver cirrhosis→ hepatocarcinogenesis, was not essential for ectopic liver developing into HCC. As ectopic liver tissue is not always as fully developed as the mother liver, in our case, the tumor was supplied by an artery not derived from the hepatic artery without the portal vein system, and the bile duct system was not found even examined under a microscope. It is theorized that due to the structure defect, the foci of ectopic liver tissue may be metabolically handicapped, leading to longer exposure to various carcinogenic factors, and finally transformed to HCC. It can explain why HCC only happens in ectopic liver and no lesion can be detected in the mother liver at the same time.Ectopic liver seems to be more prone to hepatocarcinogenesis. A review of literature suggested that approximately 100 cases of ectopic liver had been reported and HCC was detected in 28 cases up to 2011. characterized by hepatic differentiation and an excessive production of AFP.,8 Microscopic examination of HAC shows adenocarcinoma of common type intermingled with hepatoid foci.,8 In the imaging, Chang et al observed the finding of arterial phase hyperenhancement and delayed phase washout pattern in these tumors. In this case, no lesion was detected in liver, stomach, ovaries, lungs, bladder, pancreas, or uterus. Besides, the serum AFP of this patient was in the normal level and his immunohistochemical results showed negative AFP expression in the tumor. MRI showed these masses presented with heterogeneous hyperenhancement in arterial phase, and more obvious hyperenhancement can be seen in portal venous and delayed phase, no washout of the contrast agent was detected. Compared with the characteristics of HAC, we ruled out the diagnosis of HAC.One of the diseases should be considered in differential diagnosis is hepatoid adenocarcinoma (HAC). HAC is a rare subtype of extra-hepatic adenocarcinoma, most frequently originate in the stomach, also arises in the ovaries, lungs, bladder, pancreas, and uterus,Surgery resection seems to be one of the effective treatments for ectopic HCC, though it is detected with multiple tumors. In this case, the patient received surgery twice for tumor resection to attenuate the symptoms and improve his quality of life, with total survival time of 22 months. As the detailed mechanism of the development of ectopic HCC is not clear nowadays, further studies should be needed to clarify its mechanism and clinical feature, thus to improve the therapeutic effect.


We describe a case report of an infant with intussusception who presented to a pediatric emergency department with diarrhea and increased irritability. Pneumatosis intestinalis  detected on point-of-care ultrasonography  alerted the emergency physicians towards the severity of disease process. The presence of intramural air in the bowel wall or pneumatosis intestinalis in pediatric population can be due to wide range of abdominal and non-abdominal conditions. Abdominal conditions include necrotizing enterocolitis, ileo-colic intussusception with bowel ischemia, venous occlusion of the bowel vasculature and inflammatory bowel disease –4. Non-aChildren with acute intussusception present with severe abdominal pain to the emergency department (ED) . For chi2 36 mmHg, HCO3 23 mmol/L, base excess −0.6 mmol/L, Na 132 mmol/L, K 3.7 mmol/L, iCa 1.21 mmol/L, glucose 7.7 mmol/L and lactate 1.40 mmol/L. The patient was kept nil by mouth and started on maintenance intravenous fluids. A pediatric emergency physician specialized in POCUS performed an abdominal POCUS using with the low-frequency transducer (5–2 MHz) and linear transducer (8–5 MHz). This showed the presence of doughnut or target sign on the axial sonography in the left upper quadrant  to begin with to get a general overview of the abdomen. This must be followed up by a systematic scanning of the bowel using the linear transducer (8–5 MHz). Use of adjuncts such as color and power Doppler can give vital information about the blood flow in the intestinal wall. The large bowel assessment is started at the right lower quadrant then proceeding upwards along the length of the ascending colon. This is then continued to the upper abdomen along the length of transverse colon and followed by the descending colon till the left lower quadrant . To asseThe detection of pneumatosis intestinalis by POCUS done by the emergency medicine physician can alert the treating team towards the presence of an advanced stage of intussusception and bowel ischemia. These cohorts of patients’ need careful risk stratification and the decision regarding the need for surgical intervention has to be taken at the earliest . It was In this case, the POCUS result was useful in clinical decision making. Better understanding of the role of POCUS in evaluating children’s acute abdominal pain and presence of pneumatosis intestinalis can help avoid radiation exposure for diagnostic purposes in this radio-sensitive population. This case cannot be used to make conclusions about the epidemiology of intramural air and its significance in pediatric gastrointestinal pathologies nor the diagnostic accuracy of POCUS for detecting this condition in children, but suggests that further research into this promising modality is warranted.


Glioblastoma multiforme (GBM) is a malignant brain tumor with an ominous prognosis. The standard treatment includes maximal safe resection plus adjuvant therapy. Thalamic GBMs, however, are unfavorable for microsurgical removal because of deep location and proximity to critical structures. We present a patient presenting with progressive hemiparesis and decreased consciousness with a large thalamic GBM who underwent subtotal resection through a transsylvian approach. His clinical and neurologic condition improved after surgery and he survived nine months after surgery. This may propose that in selected cases, more aggressive microsurgery for debulking of tumors might have some impact in the final outcome. Glioblastoma multiforme (GBM) is the most common primary brain tumor in adults . It has Some factors make the prognosis even worse; among them are deep-seated tumors, such as thalamic GBMs. They are considered a great challenge to neurosurgeons, and are unfavorable for microsurgical removal because of the proximity to critical structures, which limits access and reduces extent of resection . For manSome studies, however, have reported subtotal resection (STR), followed by radiation therapy and chemotherapy in the management of these tumors , 5-7. AlHere, we present a patient diagnosed with a large thalamic glioblastoma who underwent STR through a transsylvian approach. His clinical and neurologic condition improved after surgery.The patient, a 63-year-old man, presented with decreased consciousness and left hemiparesis (scoring two out of five in motor exam). His family mentioned a history of progressive headache, nausea, vomiting, and decreased motor forces during the past few months. In the computed tomography (CT) scan without contrast, a hypodense mass lesion was observed within the right thalamus. Magnetic resonance imaging (MRI) showed a 5 x 5 x 4.5 cm T1 hypointense, and a T2 hyperintense lesion with strong enhancement, after Gadolinium injection in the right thalamus, with an extension to right ventricle body accompanied by significant edema, hydrocephalus, and midline shift , a right temporoparietal craniotomy was performed. After opening the dura, a standard transsylvian approach was performed under microscopic magnification. Opening the sylvian fissure from lateral to medial, a 2 cm cortisotomy was performed, and the tumor was reached at a 1-2 cm depth. The tumor was poorly defined, soft, and with a yellow to purple color. The tumor was resected in a piecemeal fashion, starting by the core. Resection was more limited in anterolateral and inferior aspects of tumor. After hemostasis, the dura mater, bone, muscle, and skin were closed. An extraventricular diversion (EVD) system was also inserted for the patient from Kocher’s point. By completion of the surgery, the patient was extubated and transferred to the intensive care unit (ICU). After surgery, his decreased consciousness fully recovered, and his hemiparesis slightly improved to three out of five. The postoperative CT showed no surgery-related complications, and the MRI showed a 3 x 2 x 1.5 cm remaining mass (an approximate 90% mass reduction) .The attempt to remove the EVD was unsuccessful due to continued hydrocephalus in brain CT and obtundation; therefore, it was converted to a ventriculo-peritoneal shunt system, CSF Flow-Control valves  after five days. The patient left the hospital 13 days after admission with complete consciousness, slightly improved hemiparesis (three out of five), and no surgery-related complications. The patient was then referred for adjuvant therapy (radiation therapy plus chemotherapy), which was not performed due to the patient's wish to forego the procedure. After nine months, the patient was diagnosed with recurrence based upon symptoms of decreased consciousness and hemiplegia, and imaging. Per family request, the patient underwent second debulking surgery, and eventually died after three weeks due to pulmonary embolism.All procedures were performed in adherence to regulations of the ethics committee of Bam University of Medical Sciences. The patient (whenever conscious and oriented) and his family gave their written consent for all procedures. GBM is classified as a high-grade glioma, and is the most common malignant primary brain tumor , 7. It iSome factors have been proposed to alter the prognosis, including age, presence of preoperative neurologic deficits, and tumor location. Deep-seated tumors in structures like the thalamus, midbrain, or brain stem have always been a great challenge in microsurgery, as GTR is limited in these locations. As a result, less tumor mass can be resected, with the final consequence of a worse prognosis . In suprFor many years, more conservative treatment paradigms, including tissue diagnosis by stereotactic or open biopsy, followed by adjuvant therapy (radiation plus chemotherapy) have been advocated as the treatment of choice . Some beHowever, the anatomy of the thalamus may allow for the possibility of surgery. The thalamus has a tetrahedron-like shape with three free surfaces; only the ventrolateral border approximates critical anatomical structures, including the internal capsule and subthalamic nucleus, and a surgical approach can be more safely made through the other surfaces , 8. BaseIn the current study, we reported a patient with a massive thalamus GBM, presenting with progressive symptoms, including decreased consciousness and significant hemiparesis, who underwent STR (>90% resection) through a transsylvian approach. The decision for the operation was made on the basis of the patient’s rapidly progressive neurologic deterioration, which was caused not only due to his hydrocephalus, but also because of his massive lesion and midline shift. We selected transsylvian approach based on certain considerations: 1) on preoperative imaging, the shortest distance between a cortical entry point and tumor surface was achieved through a transsylvian approach, since the distance between depth of sylvian fissure and tumor surface was even shorter than the distance between posterior parietal cortex and lateral ventricle, even in the presence of hydrocephalus; 2) the occurrence of tumor in the right hemisphere, which precluded damage to the language cortices; 3) the tumor could be reached by a posterior trajectory without damage to the internal capsule, though our patient was already hemiparetic before surgery; 4) in patients possessing large infiltrative structures with preoperative major neurologic deficits, many important pathways and structures are already deviated or destructed by the tumor itself.In our case, it can be assumed that the huge size of tumor had pushed motor fibers anteriorly, if not already destructed by the tumor itself, making a relatively safe corridor through the transsylvian. Given the availability of intraoperative navigation in many settings nowadays, this approach can be deployed with more safety in select cases. Our patient significantly improved after the first surgery and had no surgical complications. However, he failed to pursue adjuvant therapy, and the tumor recurred after nine months, resulting in the demise of the patient. Had he received adjuvant therapy, longer survival would have accomplished. To our knowledge, it is the first report of maximal resection in a thalamic GBM through a transsylvian approach. However, since our study was conducted in the context of a single case, more patients need to be treated and their long-term follow-ups reported, in order to make reliable conclusions.GBM is a malignant brain tumor with a poor prognosis. The prognosis gets even worse for certain anatomical locations, including brainstem or deep structures like thalami, as maximal surgical resection is further limited. We treated a large thalamic GBM in a very poor neurologic state and obtained a nine-month survival, even without adjuvant radiation and chemotherapy. The result of this limited experience suggests that in selected cases, more aggressive microsurgery with the aim of STR or GTR can be achieved in the resection of thalamic GBMs with less than expected complications. To achieve this, among many other surgical approaches, transsylvian approach may be considered as a feasible option, in exceptional cases of large tumors with pre-existing major neurologic deficits.


Pancreatic cystic neoplasm is difficult to distinguish from pseudocyst as clinical and radiological evidences may not be sufficient to make an accurate diagnosis. This may result in misdiagnosis with inappropriate management. Hence, every effort should be made for their distinction to avoid internal drainage procedures for neoplasms instead of extirpation. Cystic lesions of the pancreas comprise a heterogeneous group of diagnostic entities, which may be either benign or malignant. Pseudocysts of the pancreas are the commonest form of cystic lesions that often develop in patients of chronic pancreatitis and less commonly, in patients of acute pancreatitis. However, neoplastic cysts are not as common as pseudocysts and only 15% of the pancreatic cysts are neoplastic, benign, or malignant We present a case of mucinous cystadenocarcinoma of the pancreas which was initially misdiagnosed as pancreatic pseudocyst but the correct diagnosis was made later by which time, the disease had already metastasized.A sixty‐five‐year‐old female patient was admitted to the department of surgery in a university hospital with the complaint of an abdominal mass in the left hypochondrium for 2 months. The abdominal mass was initially localized in the left hypochondrium but gradually increased in size to progress toward the epigastric region. The mass was associated with abdominal pain and multiple episodes of nonbilious, non‐blood‐mixed vomiting. There was no history of fever, jaundice, melena, or hematemesis. She did not have any history of weight loss or loss of appetite.The patient had a prior history of multiple episodes of abdominal pain accompanied by vomiting 3 months earlier for which she was managed conservatively with analgesics, antibiotics, and antiemetics. Following third episode of abdominal pain, she felt the presence of a lump in her left upper quadrant.She was a nonsmoker but consumed nearly 500 mL of homemade alcohol (nearly 15% volume/volume) every day for the last 40 years.Clinical examination revealed slightly distended abdomen with a mass felt in the epigastric region measuring 15 × 10 cm which was soft, nontender, and not moving with respiration. There was no shifting dullness or fluid thrill and bowel sounds were heard all over the abdomen.Hematological investigations, blood sugar level, renal function tests, liver function tests, serology, blood and urine culture, amylase and lipase levels were within normal limits.Ultrasonography of the abdomen was performed which showed large well‐defined cystic appearing mass lesion measuring approximately 15 × 12.7 × 11.3 cm (volume = 1139.97 cc) in the left upper quadrant, retroperitoneal in location and that abutted the body and tail of pancreas supero‐medially. A provisional diagnosis of pancreatic pseudocyst was made.A contrast‐enhanced computed tomography (CECT) of the abdomen Figs , 2, 3, 4Her blood CEA and CA 19‐9 levels were 5.2 ng/mL and 873 U/mL, respectively, both of which were above the normal range.A final diagnosis of mucinous cystic neoplasm of pancreas was made, and the patient was planned for exploratory laparotomy. Operative finding was a huge cyst arising from the body and tail of the pancreas. The cyst was well defined and pushed the stomach anteriorly. Multiple metastases were present in the liver, omentum, and bowel, and hence, only biopsy was taken from cystic lesion and omentum. Histopathological examination revealed mucinous cystadenocarcinoma of the pancreas with peritoneal metastasis.This case report depicts similarities in presentations of both pancreatic pseudocyst and mucinous cystadenocarcinoma of the pancreas. Because of these similarities, often wrong diagnosis is made which results in faulty intervention with devastating complications.Cystic tumors of the pancreas account for 15% of all pancreatic cysts but only 1% of all pancreatic malignancies Pancreatic pseudocysts comprise 75% of cystic lesions of pancreas The presentations of mucinous cystadenocarcinoma are similar to that of pancreatic pseudocyst. Patients may present with epigastric pain, postprandial fullness, palpable abdominal mass, nausea, vomiting, diarrhea, steatorrhea, and/or weight loss Imaging with computed tomography scan (CT) and magnetic resonance imaging (MRI) can be useful to differentiate pancreatic cystic neoplasm from pseudocyst. Presence of multiple cysts and internal septations are highly suggestive of tumor In a large series of patients with resectable mucinous cystadenocarcinoma of the pancreas, a 5‐year survival of 63% was reported For pancreatic pseudocysts, surgery can be planned after 4–6 weeks of symptom onset. During this period, maturation of fibrous wall occurs that allows easier internal drainage In the presented case, the patient had multiple episodes of abdominal pain for many months prior to her presentation. This chronic history of abdominal pain was followed by the development of an abdominal mass. Besides, the patient was a chronic alcohol consumer. These clinical evidences combined with the ultrasonography findings supported the diagnosis of pancreatic pseudocyst that most probably developed on the background of chronic pancreatitis. CECT, however, showed enhancing solid nodule and areas of calcifications within the cystic lesion that suggested mucinous cystic neoplasm. This was further supported by the elevated level of CEA and CA 19‐9 in our patient. On exploration, the operating surgeons found evidences of metastases in liver, omentum and bowel and hence, decided to take the biopsy samples without radical resection of the tumor. In situations like this, the failure to correctly identify the cystic lesion as either pseudocyst or cystic neoplasm might result in serious complications. In case neoplastic lesions are incorrectly diagnosed as pancreatic pseudocysts and internal drainage procedures performed, this may result in inadequate control of symptoms, development of painful ulcers in the gastrointestinal tract with potential chances of infection, and also fail to cure a curable cancer with potential of future metastasis.Our case report highlights the fact that pancreatic pseudocyst and cystic neoplasm of the pancreas can be very difficult to distinguish from one another. Clinical evidences and radiological evaluations may not be specific enough to make a diagnosis. In our case, recurrent episodes of abdominal pain followed by the development of an abdominal mass led us to believe it as a case of pancreatic pseudocyst. But further investigations were not consistent with pancreatic pseudocyst. Hence, every effort should be made to make a correct diagnosis because of the differences in their management modalities.The authors declare that they have no competing interests.UJ: Conception and design, Acquisition of data, Analysis and interpretation of data, drafting the article, and final approval of the version to be published. PP: Conception and design, Acquisition of data, Analysis and interpretation of data, drafting the article, and final approval of the version to be published. RKG: Conception and design, critical revision of the article, and final approval of the version to be published. BB: Acquisition of data, Analysis and interpretation of data, drafting the article, and final approval of the version to be published.


We report the case of a 60-year-old man with a 12-day history of vomiting whenever he had a meal. Computed tomography revealed a calcified mass in the right cricoid cartilage with intraluminal and extraluminal extension. The patient underwent surgical resection of the trachea with end-to-end anastomosis. Pathological examination of the surgical specimen showed a low-grade chondrosarcoma. Eighteen months after surgery, the patient is alive and disease-free. Primary malignant tracheal tumors are rare, accounting for only 0.2% of all malignancies of the respiratory tract. The most frequent histology is squamous cell carcinoma, followed by adenoid cystic carcinoma and cylindroma . ChondroA 60-year-old man presented with a 12-day history of vomiting with each meal. On physical examination, a palpable, peanut-size, soft mass was found in the right side of his neck. There was no hoarseness. Plain radiography of the chest was normal. Computed tomography (CT) revealed an intraluminal, calcified mass on the right side, at the conjunction of the arch and lamina of the cricoid cartilage  based on cellularity, atypia, and pleomorphism. Grade I chondrosarcoma is also called an "atypical cartilaginous tumor." Chondrosarcoma of the trachea was first described by Moersch et al. in 1954 . A revieThe etiology remains unclear, although most authors have proposed three theories: the lesions are secondary to congenital cartilaginous rests, abnormal cartilage ossification, or chondroplasia due to chronic inflammation , 3. MohaMultiple enchondromas accompanied by multiple cutaneous hemangiomas comprise the Maffucci syndrome, which is associated with a high risk of malignant tumor development. De Almeida et al.  and WagnMost tracheal chondrosarcomas arise from the posterolateral wall of cartilaginous rings. Twenty-four cases of chondrosarcoma have been documented in the literature since 1954 and are summarized in Table Grossly, tracheal chondrosarcoma is well circumscribed and commonly covered with normal mucosa. It has been uniformly described as a firm, gray–white, multi-lobulated mass with multiple calcifications. Histopathologically, the cartilaginous tissue is usually hypercellular. Low-grade chondrosarcoma contains round and polygonal cells, nuclear hyperchromasia, large nucleolated nuclei with open chromatin, and occasionally giant nuclei , 27. LowThe tracheal chondrosarcoma may cause an obstructive syndrome depending on whether the tumor grows intraluminally or extends through the tracheal wall. The common symptoms are chronic nonproductive cough, dyspnea, and stridor, which are thought to occur when more than 75% of the tracheal lumen is occluded. Unlike previously reported cases, the patient presented herein, although vomiting after meals, showed no obstructive symptoms because the tumor had a small intraluminal component. A patient with a tracheal lesion who presents with vomiting is rather unusual, so we speculated that the vomiting was caused by the mass compressing and irritating the recurrent laryngeal nerve.Computed tomography (CT) is the modality of choice for evaluating the characteristics of tracheal tumors. It allows evaluation of the location, size, calcification, degree of obstruction, and extra-tracheal extension. Tumors occurring in the trachea and arising from the cricoid and bronchial tree are rare. Aznar et al.  describeChondrosarcomas range in diameter from 2.0 to 6.5 cm . CalcifiThe optimal treatment of tracheal chondrosarcoma is tracheal resection with free margins and end-to-end anastomosis . Among tIn conclusion, tracheal chondrosarcoma remains a rare but surgically treatable tumor. Generally, this tumor arises from the tracheal cartilaginous ring and displays intraluminal and extraluminal extension, causing tracheal narrowing. CT and ultrasound are sensitive tools for detecting calcifications scattered in these lesions in a variety of patterns. The tumor is a relatively slow-growing lesion. Its nonspecific symptoms may delay diagnosis. The treatment of choice is tracheal resection with free margins and end-to-end anastomosis. Tracheal chondrosarcoma appears to behave in a benign fashion if adequate resection has occurred. Incomplete resection is complicated by a high local recurrence rate. For patients whose disease recurs or is deemed unresectable, radiotherapy may provide local control.


Myelolipoma is a uncommon benign tumor of mesenchymal origin which consists of mature adipose tissue and normal hematopoietic cells. It occurs most often in adrenal gland  while exA 32-year-old male patient has history of peptic ulcer disease under medication for a few months, and he presented to emergency department with 1-day duration of nausea, vomiting, and epigastric pain. Abdomen in ovoid shape, tenderness over RUQ of abdomen without rebounding pain, and normoactive bowel sound were found in physical exam. ECG showed sinus tachycardia. Initially, intravenous antacids was administered under tentative diagnosis of exacerbation of peptic ulcer disease; whereas, such illness persisted. On further inquiry, the abdominal pain was irrelevant to trauma, body posture, or food intake. Laboratory data were normal except leukocytosis with white blood cell count of 19,100/uL and neutrophil predominance: 91.2%. KUB showed a huge hypodense lesion over right upper region  of abdomen. He was resuscitated with intravenous fluid hydration and blood transfusion then. And CT of abdomen revealed a huge retroperitoneal majorly fat-content mass with ruptured hemorrhage Fig. .Fig. 2CT3 were found. Total blood loss was 3500 ml. The tumor weighed 1450 g  more often multiple than solitary, 2.)frequently associated with splenomegaly and hepatomegaly, 3.)secondary to severe anemia , various myeloproliferative diseases, myelosclerosis, and skeletal disorders .In image study, computed tomography usually shows well-marginated, heterogeneous masses with macroscopic fat. Interestingly, a smoky appearance with attenuation values around 20-30HU could be found in some area of myelolipoma due to admixture of adipose and hematopoietic cells –9. Also Retroperitoneal hemorrhage due to spontaneous rupture of adrenal myelolipoma is very rare, and surgical resection is recommended –13. PersThough several theories have been proposed, the etiology of myelolipoma remains obscure. Theories include remnants of fetal bone marrow, embolism of bone marrow cells, and hyperplasia of heterotopic reticulum cells , 17. ChaManagement of myelolipoma should be done on a case-to-case basis. Patients with lesions <10 cm defined as myelolipoma on imaging procedures, should be observed closely for 1–2 years. If patient is asymptomatic and there is no tumor growth then the follow-up can be done at increasing time intervals, however the follow-up will be life-long because interval growth has been reported previously , 24.For the symptoms and signs of adrenal myelolipoma are nonspecific, it might be diagnosed as a adjunction to other main causes of illness; furthermore, adrenal myelolipoma could be asymptomatic in lifetime. In our case, however, manifesting as hemorrhage shock was challenging to diagnose step by step; instead, maintaining vital organ perfusion and identifying bleeding sources were top priorities. Management of myelolipoma should be done on a case-to-case basis.


Sclerosing angiomatoid nodular transformation is a benign disorder of splenic tissue and is often mistaken as a potentially malignant entity in the diagnostic process. To the best of our knowledge, this is the first report of sclerosing angiomatoid nodular transformation mimicking metastasis of melanoma in the literature.A 43-year-old white man presented with a newly found splenic mass 4 years ago to our Department of Gastroenterology. He was diagnosed as having a superficial spreading malignant melanoma localized at his left instep 7 years ago and was successfully treated with radical local resection. Several diagnostic procedures were conducted. Ultrasound showed a hypoechoic lesion in the inferior pole of his spleen with a diameter of 2 cm, blurred boundaries, and inhomogeneous interior pattern. Contrast-enhanced ultrasound was inconclusive and showed only discrete contrast enhancement of the lesion with accentuated nodule-like enrichment of the boundaries in the arterial phase. Computed tomography and magnetic resonance imaging scans showed two splenic lesions which were highly suspicious of metastasis. Magnetic resonance imaging of his head was inconspicuous. Bone scintigraphy showed no abnormal results. Fine-needle aspiration indicated metastasis of the above-mentioned malignant melanoma. We conducted a laparoscopic splenectomy. His intraoperative and postoperative course were uneventful. In contrast to the result of the fine-needle aspiration, the presence of metastasis of melanoma could not be confirmed. Histological analysis revealed nodule-like arrangement of fibroblasts with low cell density and a predominance of dilated capillaries, indicating sclerosing angiomatoid nodular transformation of the spleen.There are no preoperative diagnostic imaging procedures which can definitely differentiate sclerosing angiomatoid nodular transformation from malignancies in cases of morphological and immunophenotypic variations of the specimen. Morphological and immunophenotypic variations of the specimen represent a diagnostic challenge and can mimic malignoma. As reported in our case, the specimen obtained by ultrasound-guided fine-needle aspiration led to the diagnosis of metastasis of melanoma. Splenectomy is often conducted due to a splenic mass suspicious of malignoma as described in our case or with unknown valency in different diagnostic imaging procedures. Sclerosing angiomatoid nodular transformation (SANT) as a particular lesion of the spleen was initially described by Martel and colleagues in 2004 . It is gStreptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis according to national recommendations of the Robert Koch Institute. We conducted a laparoscopic splenectomy approximately 6 weeks after his initial presentation. His intraoperative and postoperative course were uneventful. He recovered well from surgery and was discharged from our hospital 5 days after the procedure. The obtained spleen was examined by our Institute of Pathology. In contrast to the result of the second FNA, the presence of metastasis of melanoma could not be confirmed. The spleen contained two suspicious lesions of 3.5 cm and 1.7 cm in diameter. Histological analysis revealed a nodule-like arrangement of fibroblasts with low cell density and a predominance of dilated capillaries, indicating SANT of the spleen . He was concerned about a possible relapse of the above-mentioned malignant disease and agreed to further diagnostic procedures and treatment. Anamnesis of current ailments and physical examination were inconspicuous. His family and psychosocial history had no abnormalities. There were no abnormal laboratory values. In the following 3 weeks, diagnostic procedures such as esophagogastroduodenoscopy, ultrasound, contrast-enhanced ultrasound , computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy, and ultrasound-guided fine-needle aspiration (FNA) were performed to rule out metastasis. The esophagogastroduodenoscopy revealed a discrete chronic type-C-gastritis, which was treated accordingly with proton pump inhibitors. Ultrasound showed a hypoechoic lesion in the inferior pole of his spleen with a diameter of 2 cm, blurred boundaries, and inhomogeneous interior pattern. CEUS (SonoVue®) was inconclusive and showed only discrete contrast enhancement of the lesion with accentuated nodule-like enrichment of the boundaries in the arterial phase  in comparison to sinusoids  and small veins  . RecentlMost patients were described as asymptomatic in the literature. Only a minority seemed to exhibit abdominal pain, splenomegaly, leukocytosis, polyclonal gammopathy, or other concurrent conditions such as: chronic lymphocytic leukemia; choroidal melanoma; carcinomas of lung, gastrointestinal tract, or kidneys; or deviating blood values , 2, 17. CT and MRI normally show hypodense/hypointense, solitary splenic lesions, but do not aid in differentiating malignant and benign entities. Conventional abdominal ultrasound most frequently shows a solitary hypoechoic lesion. In clinical practice, it is hardly possible to distinguish highly vascularized masses of the spleen according to their malignant potential or origin . KaraosmConventional abdominal and color Doppler imagings do not provide any further differential diagnostic information. SANT lesions may appear hypoechogenic or hyperechogenic and display a lack of consistency in boundaries and shapes . CEUS isSplenectomy, either as a laparoscopic or a conventional procedure, is often conducted due to the observation of a splenic mass with unknown valency in different diagnostic imaging procedures. Furthermore, most surgeons will tend to perform splenectomy if an observed splenic mass shows a tendency of growth in follow-up controls . In thisSANT is a benign disorder of splenic tissue and is often mistaken as a potentially malignant entity in the diagnostic process. There are no preoperative diagnostic imaging procedures which can definitely differentiate SANT from malignancies in cases of morphological and immunophenotypic variations of the specimen, although DWI, CEUS, and FNA seem to be promising and useful tools. However, there are only a few studies regarding DWI findings. Morphological and immunophenotypic variations of the specimen represent a diagnostic challenge and can mimic malignoma. This extends the list of possible differential diagnoses which must be taken into account and leads to further investigations and procedures like splenectomy, as reported in our case. As reported in our case, the specimen obtained by ultrasound-guided FNA led to the diagnosis of metastasis of melanoma. To the best of our knowledge, this is the first report of SANT mimicking metastasis of melanoma in the literature.


Introduction. Intestinal perforation is a known complication after colonoscopy. However, appendiceal involvement with inflammation and perforation is extremely rare and only 37 cases of postcolonoscopy appendicitis have been reported so far. We describe a case of perforated appendicitis 24 hours after colonoscopy that was treated successfully in our Department. Case Report. A 60-year-old female patient underwent a colonoscopy during the investigation of nontypical abdominal pain without pathologic findings. 24 hours after the examination she presented gradually increased right lower quadrant abdominal pain and a CT scan was performed, showing an inflammation of the appendiceal area with free peritoneal air. Through laparotomy, perforated appendicitis was diagnosed and an appendectomy was performed. The patient was discharged on the tenth postoperative day in good health condition. Discussion. The characteristics of all cases reported in the literature are described, including our case. Perforated appendicitis soon after a colonoscopy is a rare, but serious complication; therefore, it is crucial to be included in the differential diagnosis of postcolonoscopy acute abdominal pain. Colonoscopy is a common procedure used by the gastroenterologists in order to investigate abnormal conditions of the colon and the distal small intestine . SeriousPerforation is reported in 0.3% or lower of the cases examined. This complication could be caused by therapeutic interventions, air insufflation, mechanical forces, or movements of the scope . Women aAcute appendicitis has been referred to in the literature as a possible complication after a colonoscopy, probably in a higher rate than it was generally considered (until 2007 only 12 cases were reported) . HoweverWe present the case of a female patient that was submitted to diagnostic colonoscopy with normal results but presented with perforated appendicitis 24 hours after the examination. A thorough research of the literature and disclosure of the results has also been performed and recorded.μL, with 76.3% neutrophils) and imaging control through abdominal X-ray . A new abdominal X-ray was performed, presenting free abdominal gas  and 12 females (31.58%). Mean age was 54.7 years , with a range of 24 to 84 years. The time between the intervention and the presence of symptoms ranged from immediate to ten days after the procedure, with 26 patients (68.42%) showing symptoms within the first 24 hours after colonoscopy. Four patients (10.52%) were treated only conservatively; fifteen (39.47%) were submitted to exploratory laparotomy and appendectomy, seven (18.42%) to open appendectomy through McBurney's incision, and seven (18.42%) to laparoscopic appendectomy, whereas in five cases the exact treatment was not specified. Intraoperatively, acute appendicitis was diagnosed in ten cases, phlegmonous appendicitis in one case, gangrenous appendicitis also in one case, and perforated appendicitis in fourteen (36.84%), whereas nonspecified inflammation included six cases.Over 68% of the cases have presented symptoms in a 24-hour period after the procedure, which suggests that there possibly exists an etiologic relationship. Four theoretical mechanisms have been proposed for the development of acute appendicitis after a colonoscopy: preexisting subclinical appendicitis, overinsufflation, impaction of feces or fecalith in the appendix, or direct trauma .In our case, colonoscopy findings from the appendix were normal, so early appendicitis was most probably excluded from the differential diagnosis. Actually, colonoscopy is considered useful even in the diagnosis of appendicitis in cases where imaging studies are not diagnostic , so any We support that the causal event was the fecalith that could be introduced into the appendix by the air insufflation. This is suggested by no symptoms prior to the procedure, followed by the finding of impacted stool in the appendix after the open appendectomy. However, the possibility of the presence of the fecalith in the appendix prior to the colonoscopy could not be excluded, as we can also not exclude the fact that perforation could be due to overinsufflation or trauma from the scope. The presence of peritonitis could be explained by the interval of 20 hours from the moment of the presence of mild postcolonoscopy symptoms until the surgical management.It could be suggested that the presence of fourteen cases of perforation intraoperatively could be due to a delay of diagnosis and deteriorated condition; however, even the immediate diagnosis and treatment  show thaCT is the examination of choice in order to obtain the optimal preoperative abdominal image, as postcolonoscopy abdominal pain can be generally caused by retained gas, colonic spasm, or postpolypectomy syndrome . ExploraPostcolonoscopy appendicitis may be incidental or the result of the procedure. The mechanism of this complication is still unknown and theoretical. However, acute appendicitis should be always included in the differential diagnosis of postcolonoscopy abdominal pain, in order to avoid a delayed or complicated diagnosis and treatment.