Severe spinal trauma is uncommon in the pediatric population, but due to the potentially devastating consequences of missed injury, it poses a diagnostic challenge in emergency departments. Diagnostic imaging is often needed to exclude or confirm the injury and to assess its extent. Magnetic resonance imaging (MRI) offers an excellent view of both bony and soft tissue structures and their traumatic findings without exposing children to ionizing radiation. Our pictorial review aims to demonstrate the typical traumatic findings, physiological phenomena, and potential pitfalls of emergency MRI in the trauma of the growing spine. Imaging plays a crucial role in the workup of suspected pediatric spinal trauma . The accMRI is more expensive and time-consuming per single scan than plain radiographs and CT. Its availability is often limited, and the drawbacks also include a more frequent need for anesthesia to obtain diagnostic image quality, especially in the preschool-aged population. However, in addition to the health benefits of accurate imaging, the overall cost-effectiveness of emergency MRI in clearing the cervical spine of an obtunded pediatric patient has been found to be positive due to shorter ICU and hospital stays . With skOur pictorial review provides an overview of certain traumatic findings and some physiological phenomena in emergency MRI of the pediatric spine . The majAccording to the current ACR Appropriateness Criteria on Suspected Spine Trauma in children, MRI is categorized as “May Be Appropriate” regarding its consideration as an alternative to plain radiographs for initial imaging in children under 16 years of age with a suspected cervical or thoracolumbar spine injury and the risk factors justifying spinal imaging  and is hYounger (particularly <5 years of age) and critically ill children require sedation through anesthesia to achieve sufficient imaging quality. Careful decision making regarding the most suitable imaging method must be conducted case by case in this age group. The first principle should be adequate imaging for prompt diagnosis. Nonetheless, the risks of ionizing radiation and sedation must also be taken into consideration when planning the imaging of these vulnerable patients . Runge eAny patient with high-energy trauma should be examined according to standardized trauma protocols, including whole-body and cervical CT scans , followeOur routine imaging protocol includes sagittal T1- and T2-weighted, sagittal and coronal STIR, and axial T2-weighted. In the case of either clinical or radiological suspicion of a ligamentous injury in the upper cervical spine and craniocervical junction, the following series with a small field of view (FOV) are obtained: sagittal and coronal PD-weighted and axial T2-weighted. Contrast media are not used in the routine protocol. The device used is a Philips Ingenia 3 Tesla scanner with a Philips dStream coil system . Detailed specifications of the routine sequences adopted in our clinical practice can be found in In concordance with previously published observations , we haveMRI has a high negative predictive value in spinal fractures. Fat-suppressed sequences, particularly short tau inversion recovery (STIR), are the most sensitive in acute trauma . T1- andCompression fractures may occur in any spinal segment. Over 80% of these injuries in children affect more than one level ,27. CompPediatric chance fractures are rare high-energy injuries often caused by motor vehicle accidents. The most commonly affected levels are L2 and L3 . CT is cMost avulsion fractures of the pediatric spine occur in levels C0–C2, being avulsions of craniocervical ligaments, the alar ligament in particular ,33,34. TAcute clay-shoveler-type spinous process avulsion fractures are also seen, usually in teenage athletes . On MRI,Fractures of the vertebral arch, spinous process, transverse process, and facet joints can also be identified in MRI . As withIn ligamentous injuries, MRI is superior to any other imaging modality. Ligamentous discontinuity and possible spinal malalignment are most easily assessed on T2-weighted and STIR sequences. STIR demonstrates an edematous signal in partial tears or ligament strains without visible structural changes. The threshold for performing MRI should be especially low in suspected craniocervical junction trauma .The craniocervical and atlantoaxial joints are mobile structures allowing flexion–extension movement and rotation of the head. The joints’ biomechanics and the importance of different stabilizing structures are not yet completely understood. The joint capsules, the alar ligaments, and the transverse ligaments are crucial to stability ,38,39. TThe posterior ligament complex (PLC) consists of the ligamentum flavum, interspinous ligament, supraspinous ligament, and facet joint capsules. It is noted as an essential factor for spinal stability in numerous classification systems proposed for spinal trauma . Of thesIn addition to a widened interspinous distance and other indirect measures used with CT and plain radiographs, MRI can differentiate the very components of the PLC, revealing the culprits responsible for the indirect CT findings .Anterior and posterior longitudinal (ALL and PLL) injuries occur as part of a gross fracture–dislocation. The literature on the pediatric population’s isolated or non-dislocated ALL or PLL injuries is scarce. These injuries might be rare, especially in younger children , but theAs with any intervertebral disc pathology, acute traumatic disc injuries are best seen with MRI . The higMRI is the gold standard in the imaging of muscular trauma . Spinal Treatment planning in nerve plexus injuries requires dedicated imaging ,56. HoweCTA has been a workhorse in suspected vascular trauma for decades. On a routine cervical spine MRI, an arterial injury can be detected as an abnormal flow void in T1-weighted, T2-weighted, STIR, and proton density sequences . Vessel The use of MRI in acute spinal cord trauma was first described in 1983 ,61 and iSpinal cord injury without radiographic abnormality (SCIWORA) is mainly seen in children, although it also exists in adults. The term was first described by Pang and Wilberger in 1982 , but symThere are many practical issues to take into account when interpreting the emergency MRI of the pediatric spine. Some of these are universally related to MRI, but children have many peculiarities that the radiologist and the physician must be aware of. The following list is not comprehensive but might help in avoiding some pitfalls.Pseudosubluxation in the subaxial cervical spine is a normal variant in younger children, and it is essential to distinguish it from true subluxation. Pseudosubluxation is most commonly seen in level C2/3, followed by level C3/4 ,74,75,76Anterior wedging of the vertebral bodies is a normal physiological phenomenon that disappears gradually with skeletal maturation ,78,79. WJuvenile lumbar spondylolysis ensues from repetitive stress, but the onset of symptoms can be sudden, and the chronic pain may be exaggerated by acute trauma. The clinical presentation and the typical location of the findings centered in the pars interarticularis help to distinguish a stress injury from an acute traumatic fracture. The spondylolysis and surrounding bone marrow edema can probably be assessed with MRI , but theEvery radiologist performing pediatric imaging must be aware of the fundamentals of skeletal maturation . On the The pulsatile movement of cerebrospinal fluid (CSF) causes flow void artifacts, especially on T2-weighted sequences. The artifacts can occur anywhere in the subarachnoid spaces, but, in the spine, they are often most prominent in the cervical and thoracic regions ,93. UsuaMR imaging is highly susceptible to patient movement. In the pediatric population, motion artifacts may often become an issue. As described above, the circumstances must be appropriate and child-friendly to obtain sufficient image quality. The imaging protocol needs to be optimized to be as quickly as possible, and the most crucial sequences should be obtained first .Compared to the adult population, ferromagnetic implants and other foreign bodies in the spinal region are uncommon among children. Dental braces are often seen, but, unlike brain MRI, they seldom cause significant challenges in spinal imaging. Braces inflict susceptibility artifacts, but the extent of the artifact is usually limited outside the area of interest . NaturalMRI offers a radiation-free alternative in imaging pediatric spinal trauma, providing an excellent view for both bony and soft tissue injuries. The need for sedation can be diminished with calm and child-friendly conditions and dedicated staff, especially in children older than 5 years, making MRI more approachable in clinical practice. Younger children require sedation or anesthesia. To understand traumatic findings, the radiologist must be aware of the fundamental characteristics of the growing spine.


A 60-year-old male patient who presented with right upper quadrant (RUQ) pain was diagnosed with acute cholecystitis after an ultrasound of the abdomen revealed multiple gallstones, gallbladder wall thickening, pericholecystic fluid, and a positive sonographic Murphy sign. The patient was admitted, administered IV fluids, antibiotics, and pain relief, and scheduled for laparoscopic cholecystectomy. During surgery, an incidental finding of ectopic liver tissue attached to the gallbladder was noted. Histopathology confirmed the presence of chronic cholecystitis and multifaceted cholesterol stones. Normal liver tissue was noted in the ectopic mass. Ectopic liver tissue is defined as liver tissue located outside the main liver parenchyma and is usually asymptomatic. They are usually detected at the time of autopsies, incidentally during surgeries, or during imaging done for other etiologies. They can occur at various sites in the body. Ectopic liver tissue can cause potential complications such as hepatocellular carcinoma and torsion, and in the event that they are incidentally detected, it is advised to remove them. The case report highlights the importance of dealing with incidental findings during laparoscopic cholecystectomy and creating awareness about it. Variations in anatomy often lead to incidental discoveries during surgical procedures . EctopicThis report presents a unique case of an ectopic liver mass discovered during laparoscopic cholecystectomy, one of the most frequently performed surgical procedures worldwide . BecauseFurthermore, this report highlights the embryology of ectopic liver tissue, providing insight into the mechanisms behind its occurrence in varied body sites, including the spleen, umbilicus, vena cava, heart, and lung . EctopicThe patient is a 60-year-old male with a past medical history of hypertension and on a daily 5 mg regimen of amlodipine who presented with acute right upper quadrant (RUQ) pain that started suddenly. The pain was severe, with an intensity of 8/10, and radiated to the back. The patient reported he had been having episodes of RUQ pain in the past, but this time, the pain persisted and only partially subsided with antacid use.Physical exam was significant only for a positive Murphy sign. On initial evaluation, vital signs were stable. Laboratory investigations revealed slight leukocytosis, with a white blood cell count of 11,800 cells per microliter . All other lab investigations, including hematocrit, renal function tests, liver function tests, amylase, and lipase levels, were within normal limits. An ultrasound of the upper abdomen was conducted which revealed multiple gallstones. The ultrasound also showed gallbladder wall thickening, pericholecystic fluid, and a positive sonographic Murphy sign which were consistent with a diagnosis of acute cholecystitis. The diameter of the common bile duct was normal, and there was no dilation of the intrahepatic biliary radicles. The liver parenchymal echogenicity was homogeneous (Figure The patient was admitted, hydrated with IV fluids, and administered antibiotics and pain relief. We decided to take the patient up for laparoscopic cholecystectomy the coming morning after informed consent was taken, including consent for an open procedure in case a conversion was required. While in the operating room, pneumoperitoneum was established with ease, and the gallbladder was easily retracted. The gallbladder was inflamed, but there were not many adhesions to the omentum. After dissection of the hepatocystic triangle, the cystic duct and artery were easily identified and ligated. During the dissection of the gallbladder from the liver bed, we realized that there was a small tissue with its own blood supply present on the gallbladder. The color and texture of the tissue were the same as that of the liver Figure .We identified it to be a remanent ectopic liver tissue. We were careful in our dissection of the gallbladder from the liver bed taking care not to avulse the blood supply of the ectopic tissue. Therefore, we dissected the feeding blood vessel and applied another clip to it to prevent postoperative bleeding. Hence, an incidental finding of a small liver-like tissue adherent to the medial surface of the gallbladder was noted Figures , 4.The gallbladder, along with the ectopic liver tissue, was sent for histopathology. Postoperatively, the patient was informed about the incidental findings. The patient's postoperative stay was uneventful. He was later discharged with advice to avoid fatty foods for a couple of weeks. Histopathology results later revealed chronic cholecystitis and multifaceted cholesterol stones and confirmed the presence of normal liver tissue in the ectopic mass adherent to the gallbladder.Laparoscopic cholecystectomy is the most commonly performed surgical procedure  and is aEctopic liver tissue is defined as liver tissue located outside the liver that has no connection with the main liver parenchyma .DiagnosisThey are usually asymptomatic and detected incidentally during surgery or autopsy, but they can be seen when a soft-tissue mass arises from the gallbladder wall on abdominal ultrasound or CT scan . HistopaIncidence and diagnosisIn a study of 5,500 autopsies, only 0.05% revealed the presence of ectopic liver tissue, with only three cases specifically showing attachment to the gallbladder wall . In anotLocation of ectopic hepatic tissueAn ectopic liver can occur in varied sites of the body. They have been found in the spleen, umbilicus, vena cava, heart, and even the lungs . There hCollan et al. classified ectopic liver depending upon location into four categories . The firEmbryology of ectopic liver tissueVarious theories have emerged to elucidate the mechanisms underlying the occurrence of ectopic liver in different locations. These theories encompass concepts such as the development of accessory liver lobes, migration or displacement of liver bud, dorsal budding of hepatic tissue, entrapment of hepatocyte-destined mesenchymal cells, and the entrapment of cell nests in the foregut region .Complications of ectopic liver tissueThe presence of ectopic liver tissue is frequently associated with inadequate biliary drainage and reduced blood supply, which has been suggested as a possible explanation for the heightened susceptibility to hepatocellular carcinoma in individuals with this condition . MultiplImportance of vascular supply Bal et al. described a mass with a unique blood supply [Knowledge of the vascular supply becomes important for the removal of ectopic tissue.d supply . Our casd supply . Three vd supply .Surgical intervention is necessary for identifying the vascular supply and preventing bleeding . CautionLundy et al. suggested that laparoscopic management of the ectopic liver is safe and effective and may offer advantages such as reduced postoperative pain, shorter hospital stay, and faster recovery compared to open surgery . They alAssociations with other congenital abnormalitiesPark et al. reported a case of umbilical liver and biliary atresia . FurtherOur caseOur case had a small ectopic liver mass attached to the medial surface of the gallbladder. The mass was not seen on ultrasound. In our case as well, there was a similar case described by Bal et al. . The masEctopic livers are often diagnosed at autopsy, incidentally during surgery, and had imaging done for other issues. Ectopic liver tissue is a rare developmental anomaly and occurs along with other congenital abnormalities. The unique intraoperative finding of ectopic liver tissue adherent to the gallbladder underscores the importance of a meticulous surgical approach. Ectopic livers are associated with an increased propensity to develop hepatocellular carcinoma, abdominal pain due to torsion, and other complications. Therefore, it is always prudent to remove incidentally found ectopic livers during laparoscopy. Ectopic livers can potentially complicate the procedure if they are larger in size. Hence, it is important to create awareness about such findings.


Genetic analysis allowed for the exclusion of pathogenic mutations in genes implicated in hereditary paragangliomas and pheochromocytomas but showed a rare somatic mutation in exon 3 of the von Hippel-Lindau gene. The patient was treated with a β-blocker and calcium channel antagonist and underwent laparoscopic right-sided adrenalectomy. Cardiac manifestations resolved soon after surgery indicating that they were secondary to the pheochromocytoma. After 5 years of follow-up, the patient remains asymptomatic without any sign of tumor recurrence. The presence of aortic root dilation, a prolonged QT-interval and left ventricular hypertrophy may be early cardiac manifestations of a pheochromocytoma in a child and should prompt this diagnosis to be evoked.We report the case of an 11-year-old girl who complained about severe asthenia, orthostatic dizziness and abdominal pain for 4 weeks. The primary investigation concluded on febrile urinary tract infection treated by antibiotics. Symptom persistence prompted cardiological and endocrinological investigations. A fluctuation in blood pressure, long QT interval, dilation of the aortic root and left ventricular hypertrophy were documented. Elevated levels of urinary catecholamines together with the presence of a right-sided adrenal mass shown via abdominal ultrasound and magnetic resonance imaging were highly suggestive of a pheochromocytoma. This was confirmed by through iodine-123-metaiodobenzylguathdine ([ Pheochromocytoma is a rare neuroendocrine tumor belonging to the family of neural crest cell-derived neoplasms arising from adreno-medullary chromaffin cells. Pheochromocytoma in children has an incidence of 0.11 per million and is more frequently familial (40%), bilateral 20%) and malignant (10%) compared to that in adults 0% and ma. This tu123I]-mIBG) scintigraphy must be undertaken in order to improve diagnostic specificity and sensitivity and to detect metastases and multifocality.In cases of proven abnormal catecholamine production, a diagnostic work-up is completed via anatomical imaging with abdominal sonography and magnetic resonance imaging of the kidney and the adrenal lodges. In addition, functional scans, such as iodine-123-metaiodobenzylguathdine  but increased sedimentation rate (68 mm/h), and slightly increased fasting glycemia (106 mg/dL) with a normal insulin concentration. Urine analysis showed bacteriuria. On that basis, she received a treatment with sulfamethoxazol.Patient status did not improve, and thus, she was referred to our institution for endocrinological and cardiological advice. A physical examination confirmed recent weight loss (2.5 kg in 10 days), systemic arterial hypertension (147/104 mm Hg) in an upright position dropping in a supine position (80/60 mm Hg), a normal heart rate and normal transcutaneous oxygen saturation.The patient was pale with wet and cold extremities. Precordium was hyperactive, and cardiac and pulmonary auscultation was normal as was abdominal palpation.An electrocardiogram showed left ventricular hypertrophy according to Davignon’s criteria  with nonEchocardiography demonstrated global left ventricular hypertrophy with a dilated aortic root  anAbdominal ultrasound showed the presence of a right-sided adrenal mass .The left-sided adrenal gland and all other intra-abdominal organs were normal.123I]-mIBG) scintigraphy confirmed isolated tracer fixation on the right adrenal gland . The right-sided adrenal mass was confirmed via magnetic resonance imaging , and iodal gland .The patient was scheduled for surgery and stabilized until then using a combination of a β-blocker and calcium channel antagonist, allowing for blood pressure control. She underwent total adrenalectomy via laparoscopy. Anatomo-pathology confirmed the diagnosis of a typical pheochromocytoma without any signs of malignancy.Microscopic analysis showed a nest-shaped tumor architecture with large polygonal cells. The central part of the tumor presented some ischemic necrotic areas and vascular structures with recent thrombosis but no signs of vascular invasion. There was no mitotic activity.Immune-histological examination proved a high degree of positivity for the neural cell adhesion molecule CD56 and for the markers of neuroendocrine tumors chromogranine and synatophysine. The level of cell proliferation was estimated to be lower than 1%.A genetic evaluation was carried out. DNA sequence analysis allowed for the exclusion of pathogenic gene mutations implicated in hereditary paragangliomas and pheochromocytoma  but demonstrated a somatic mutation c.57C>T in exon 3 of the tumor suppressor gene von Hippel-Lindau.Cardiac examination, including echocardiography performed 2 weeks after right-sided adrenalectomy, showed residual left ventricular hypertrophy but normalization of the aortic root dimension (Z-score: 0.7) and QTc duration .Two years after the operation, the patient complained about dizziness, palpitations and chest pain. The clinical examination, including blood pressure, was normal. Concentrations of blood and urine catecholamines were in the normal range. Abdominal MRI showed a normal left-sided adrenal gland an empty right-sided adrenal lodge. Endocrinological and cardiological examinations, including echocardiography and abdominal MRI, were repeated and remain normal after a follow-up period of 5 years.Pheochromocytoma is a rare tumor arising from adreno-medullary chromaffin cells. Commonly, it manifests as headache, palpitations and hyperhydrosis in adults and in children as well ,8.In most patients, multiple cardiac manifestations are found, such as systemic arterial hypertension, a prolonged QT interval, dilated or hypertrophic cardiomyopathy, arrhythmias and more rarely myocarditis ,10.To the best of our knowledge, it is the first reported case of a child with pheochromocytoma and aortic root dilation. All yet reported cardiac manifestations of pheochromocytomas and paraganglioma are characterized by an acute and dramatic clinical presentation with a high complication rate, particularly in patients in whom diagnosis is delayed.Indeed, the catecholamine storm induced by the tumor may provoke acute coronary vasospasm with myocardial ischemia, increased inotropism with a hypercontractile state of cardiomyocytes and possible sarcomere rupture. If the patient survives, myocardial cell necrosis will finally lead to the infiltration of inflammatory cells and myocardial fibrosis causing, in turn, ventricular dysfunction . SystemiAlthough most patients have either sustained or paroxysmal systemic arterial hypertension, some patients present with malaise due to orthostatic hypotension as was the case in our patient. Indeed, the excess of catecholamine release may cause baroreceptor desensitization and consecutive hypotension .Left ventricular hypertrophy is also a classic complication. A study of 26 consecutive patients with pheochromocytoma reported concentric left ventricular hypertrophy at echocardiography in 37.9% of them [The cardiac manifestations of pheochromocytoma are the consequence of the catecholaminergic impregnation. The cardiovascular responses to released catecholamine depend mostly on their quality and quantity.Indeed, epinephrine and norepinephrine have a predominant effect on beta-adrenergic receptors and increase inotropy and chronotropy. They also have, to a lesser extent, an alpha adrenergic effect that induces an increase in cardiac output and systemic vascular resistance .It is the alpha adrenergic stimulation that is responsible for systemic arterial hypertension, while the beta effect rather leads to the hypertrophic response. However, due to the down-regulation of the adrenoreceptors as a consequence of prolonged excessive levels of circulating cathecolamines, these symptoms are not constant .The prolongation of the corrected QT interval has been reported in 16% to 35% of patients with pheochromocytoma ,16. A prIn children, aortic root dilation in the context of pheochromocytoma has not been reported previously. The mechanisms by which the aortic wall becomes distended in cases of pheochromocytoma may be due, at least in part, to acute systolic systemic arterial hypertension. Beside this, aortic wall damage may also be involved. Indeed, cases of aorto-arteritis have been reported as complications of pheochromocytoma in young adults for whom symptoms lasted for months. The complex and multi-factorial mechanisms causing aortic wall inflammation involve mechanical stress due to systemic systolic hypertension and aortic wall ischemia due to vasa vasorum constriction leading in turn to media necrosis and elastic layer destruction . A catecOur case highlights the fact that in a patient with alteration of the general state, cardiac manifestations, such as left ventricular hypertrophy, a prolonged QT interval and aortic root dilation, must suggest a diagnosis of a pheochromocytoma.An unclear issue in our case is the particular family history of our patient. Indeed, there is currently no known link between pheochromocytoma and pericardial agenesia, both rare diseases presented by siblings. Our patient with pheochromocytoma showed a somatic mutation of the von Hippel-Lindau gene without an associated germline mutation. According to the literature, this mutation is extremely rare ,24,25.International guidelines recommend genetic testing be performed for all patients with pheochromocytoma regardless of their age and their personal or family history. Indeed, a constitutional mutation of a predisposition gene is present in more than 40% of patients. Since the risk of recurrence is estimated to be 1 per 100 person-years, close follow-up is recommended. This should be annual and include blood and urine concentrations of catecholamines as was performed for our patient.Recommended follow-up should be lifelong, especially in patients carrying a higher risk of recurrence, such as those of younger age, patients with a paraganglioma, a germline mutation, with an extra-adrenal or large tumor, or with a syndromic disease ,27.Specific cardiological follow-up will depend on the type of complications induced by massive catecholamine production. While systemic arterial hypertension and electrophysiological anomalies usually resolve after tumor resection, cardiomyopathies due to long-lasting hyperactivation of the sympathetic nervous system or even acute coronary artery syndrome and consecutive myocardial ischemia determine long-term cardio-vascular morbidity .Pheochromocytoma in children is a rare tumor, and its diagnosis might be challenging due to the non-specific and confusing clinical signs. Recognizing the cardiac manifestations as acquired electrophysiological and morphological alterations due to excessive catecholamine production may be lifesaving in accelerating diagnosis and offering prompt adequate curative treatment. Depending on the type of complications, cardiological examinations may be indicated in addition to the recommended long term oncological and endocrinological follow-up.


Small-bowel diverticulosis is rare. We report the case of a male with an acute abdomen secondary to an ileal diverticulum. A 46-year-old male complained of progressive abdominal pain over 24 hours of evolution in the left flank. On physical examination, we found abdominal pain in the left flank and mesogastrium, tenderness, and signs of peritonitis. The simple abdominal CT showed a heterogeneous tubular image in the small bowel. We performed a diagnostic laparoscopy and found a normal cecal appendix. There was no free abdominal fluid or adhesions, and the colon was without diverticula. We found a single diverticulum of 4 cm in length and 2 cm in diameter in the small intestine and therefore converted the procedure to a laparotomy. We performed a bowel resection including the diverticulum and intestinal anastomosis. The patient reported remission of symptoms after surgery. Small bowel diverticulosis is rare, with a prevalence of 0.3% to 2.3%. Diverticula are herniations of the mucosa and submucosa of the intestine . Most paA 46-year-old male, without any significant past medical history, presented with the complaint of progressive abdominal pain in the left flank for the past 24 hours. He denied having fever, nausea, a change in his evacuation pattern, or vomiting. On physical examination, his vital signs were normal, but on palpation, we found abdominal pain in the left flank and mesogastrium, tenderness, and signs of peritonitis. The laboratory examination revealed a white blood cell count of 19,500 per mm3, with the rest of the test results normal. The simple abdominal CT showed a heterogeneous tubular image in the small bowel (Figure We performed a diagnostic laparoscopy and found no evidence of an inflammatory process in the cecal appendix. There was no free abdominal fluid or adhesions, and there was no diverticula in the rest of the small bowel and colon. We found a single diverticulum of 4 cm in length and 2 cm in diameter in the small intestine (Figure Therefore, we converted the procedure to a laparotomy. We performed a bowel resection of 10 cm, including the diverticulum, and intestinal anastomosis. The diverticulum was located in the ileum at 280 cm from the ligament of Treitz and 100 cm from the ileocecal valve. The patient reported remission of symptoms after surgery and was discharged on the fifth postoperative day.Diverticulosis of the small intestine occurs more commonly in men between the sixth and seventh decades of life . In ordeMost patients are asymptomatic; the clinical presentation is nonspecific. It can be intermittent chronic abdominal pain, constipation, diarrhea, dyspepsia, intestinal occlusion, or an acute abdomen with evidence of peritonitis ,7. The cThere is no consensus about its treatment. If the inflammation is mild, it can be treated conservatively, with the risk of recurrence of diverticulitis. In cases of surgical management, the treatment of choice is resection of the affected intestinal segments and anastomosis . MortaliSince small-bowel diverticulitis is rare, a delay in its diagnosis increases its morbidity and mortality. It should be among the differential diagnoses of acute abdomen that a surgeon considers. High suspicion is required for diagnosis, and a CT scan is the imaging technique of choice. When an imaging diagnosis is not possible and suspicion is high, a diagnostic laparoscopy should be performed. We recommend surgical treatment to prevent recurrences, including resection of the segment with the diverticulum and primary anastomosis.


Perforation is a rare but fatal complication of pancreatic pseudocysts. It is generally diagnosed by computed tomography imaging with hemorrhagic ascites and pneumoperitoneum. Traditionally, surgery was the mainstream for treating this critical state. Recently, alternative therapies have also been deemed useful. Herein, we describe the case of a 54‐year‐old with perforation of pancreatic pseudocyst which was confirmed by endoscopy, and managed by endoscopic and percutaneous drainage. The patient was initially referred to our hospital for treatment of a pancreatic pseudocyst with hemorrhagic ascites and underwent endoscopic ultrasonographic‐guided stent placement. The next day, imaging demonstrated pneumoperitoneum and worsening ascites consistent with perforation, and the patient was treated conservatively. One week later, the patient developed severe abdominal pain. Endoscopy showed a large perforation site inside the pseudocyst connected to a large fluid collection and direct visualization inside the pseudocyst and fluid collection. The fluid collection was treated with percutaneous drainage, and the patient was discharged one week later with no complications. Perforation of a pseudocyst is a rare lethal complication of pancreatic pseudocysts, occurring in less than 3% of all cases.3, absolute neutrophil count 12,300/mm3, hemoglobin 10.4 g/dL, and platelets 522 × 109/L.A 54‐year‐old male with a history of chronic pancreatitis presented with upper abdominal pain to an outside hospital, where an abnormal peripancreatic mass was discovered on a computed tomography (CT) scan. He was subsequently referred to our hospital for further evaluation and treatment of the mass. The laboratory tests on admissions were as follows: white blood cell count 15,300/mmA CT scan showed a 90‐mm large rim‐enhancing complex fluid collection arising from the pancreatic tail and extending along the greater curvature of the stomach, indicative of a pancreatic pseudocyst with thickened internal debris or hemorrhage. The CT scan also revealed complex hemorrhagic ascites in the peritoneum throughout the dependent portions of the abdomen and pelvis Figure , which wOn the second day of admission, EUS was performed, confirming the presence of a 90‐mm hypoechoic lesion with fluid and internal debris echogenicity at the tail of the pancreas consistent with a pancreatic pseudocyst. A 15 × 10‐mm lumen‐apposing metal stent  was deployed for cystogastrostomy, subsequently dilated with 15‐mm balloon dilation, followed by hydrogen peroxide lavage, endoscopic irrigation, and removal of hemorrhagic materials and debris. Figure . On the 3). A CT scan showed a new giant 20 cm fluid collection containing hemorrhage and an extensive amount of free air along the greater omentum, communicating with the previously treated pseudocyst treated with the LAMS. The gastric lumen was sandwiched between the pseudocyst and the peritoneal fluid collection (Figure On the ninth day, however, the patient developed an acute onset of severe abdominal pain, nausea, and neutrophilic leukocytosis (absolute neutrophil count 17,100/mmn Figure . An emern Figure . When thn Figure . The patSpontaneous perforation of a hemorrhagic pancreatic pseudocyst is an exceedingly rare complication, but it can be extremely fatal if not managed promptly and properly. The perforation can either occur in the gastrointestinal tract lumen or the peritoneal cavity.Early identification and diagnosis of perforation of pancreatic pseudocyst at an early stage can be challenging. Most case reports of perforated pancreatic pseudocysts rely on CT scans for diagnosis, which typically show a significant amount of free fluid and air in the peritoneal cavity. Additionally, physical examination findings indicative of peritonitis such as abdominal tenderness and guarding, along with signs of systemic inflammation and hemodynamic instability, can aid in the diagnostic process.In the literature, this is the first reported case of endoscopic visualization of an actual perforation extending to the perineum, providing valuable insights into the presentation and pathophysiology of this complication and its further management.Traditionally, the management of a perforated pseudocyst involved emergent surgical exploration and external drainage, as leaving pancreatic fluid in the peritoneum could further exacerbate organ lysis.In conclusion, we report a rare case in which the site of perforation in a pancreatic pseudocyst was successfully visualized and examined by endoscopy. Percutaneous drainage effectively treated the new fluid collection caused by the perforated pseudocyst, while the pseudocyst itself was managed with the LAMS. This case highlights the usefulness of direct visualization of the pseudocyst perforation and the potential benefits of combined endoscopic and percutaneous drainage for managing perforated pancreatic pseudocysts.Dr. Yusuke Hashimoto is a consultant of FUJIFILM and has received honoraria from the American Society of Gastrointestinal Endoscopy.Video S1 Video of a CT scan and endoscopy on the ninth day, when the perforation site was confirmed.Click here for additional data file.


Mediastinal neurogenic tumors primarily originate from the intercostal and sympathetic nerves, whereas schwannomas originating from the brachial plexus are rare. Surgical intervention for such tumors is complex and associated with the risk of postoperative upper limb dysfunction due to their unique anatomical location. In this report, we present the case of a 21-year-old female diagnosed with a mediastinal schwannoma, who underwent a novel surgical approach combining cervical incision and intercostal uniportal video-assisted thoracoscopic surgery (VATS). Our study reviewed the patient’s clinical presentation, treatment approach, pathology, and prognosis. The findings of this study demonstrate that the cervical approach, combined with intercostal uniportal VATS, is a feasible surgical method for the removal of mediastinal schwannomas originating from the brachial plexus. Mediastinal neurogenic tumors account for approximately 20–30% of all mediastinal tumors in adults , 2. MediHere, we report a novel method that combines a cervical approach with intercostal uniportal video-assisted thoracoscopic surgery (VATS) exclusively for resection of mediastinal schwannomas of brachial plexus origin.2A 21-year-old female presented to the hospital with a mass in the superior mediastinum that was incidentally discovered during a routine physical examination. The patient did not report any symptoms such as chest or shoulder pain, numbness, weakness, or loss of function in the upper limbs, nor did she exhibit any other discomforting clinical manifestations. Further inquiry revealed no history of diabetes, hypertension, or any relevant tumorous diseases. Blood examinations, including tumor markers, biochemistry, complete blood count, arterial blood gas and other pertinent indicators, were unremarkable. Additionally, pulmonary function tests and electrocardiography demonstrated normal results.Contrast-enhanced computed tomography (CT) of the patient’s chest revealed a well-defined mass, measuring approximately 33mm in diameter, adjacent to the mediastinum of the upper lobe of the left lung , a 10-mm 30° thoracoscope, operational draw hooks, long curved endoscopic instruments with curved suction and double articulations. The patient was placed under general anesthesia, and a double-lumen endotracheal tube was used for single-lung ventilation. The procedure began with the upper pole of the tumor, and an approximately 8 cm curved incision was made horizontally along the left supraclavicular, extending from the midfront of the neck to the anterior edge of the left sternocleidomastoid muscle  for the publication of any potentially identifiable images or data included in this article.LW drafted the manuscript. Data acquisition was performed by LW. LW and LG designed the analysis. YR and LW conceived of and designed the study. All authors contributed to the article and approved the submitted version.


Multiple brown tumors are more common in females and older age groups and an unlikely site is the long bones. We report a case of a 21-year-old male presenting with a pathological fracture at the left neck of the femur. Laboratory investigations showed elevated parathyroid hormone (PTH) and serum calcium levels . A CT scan revealed multiple osteolytic lesions in the pelvis and femurs, and a Tc-99m sestamibi scan showed a solitary parathyroid adenoma. We demonstrate this rare case and illustrate the importance of the consideration of multiple brown tumors in young males presenting with multiple osteolytic lesions at the long bones in the differential diagnosis. Every physician needs to have a high clinical suspicion of primary hyperparathyroidism innovation, in those who present with osteolytic lesions, with respect to the patient’s age and gender. Parathyroid glands secrete parathyroid hormone (PTH) under the control of the ionized calcium level . PrimaryBrown tumor, also called osteitis fibrosa cystica, is a benign intraosseous tumor that occurs due to osteoclast hyperactivity in hyperparathyroidism . It is aThe clinical presentation is variable, but some patients have nonspecific generalized muscle weakness, fatigue, recurrent urinary stones, and fractures . Brown tPlain radiographic findings include multiple osteolytic lesions, subperiosteal resorption, and osteopenia . SestamiThe key treatment for primary hyperparathyroidism when imaging techniques show a parathyroid adenoma is the excision of enlarged parathyroid glands. Bone deformities caused by it usually spontaneously disappear with the treatment of hyperparathyroidism . PostopeBrown tumors are more common in females than males, with a reported ratio of five females to four males; they also affect older patients, usually in the fifth and sixth decades of life ,17.Here, we describe a case of multiple brown tumors caused by a parathyroid adenoma that presented with a pathological fracture and was treated with surgical intervention.A 21-year-old adult male, with no relevant past medical and surgical history, presented to the emergency department complaining of severe left hip pain and an inability to bear weight after he slipped and fell from a 1-meter height. Immediately, he was unable to mobilize his left lower leg. He also complained of generalized body aches and easy fatigability. On examination, there was left hip joint tenderness and an external rotation deformity of the left lower leg. There were no wounds, and distal neurovascular examinations were intact. Examination of other joints was within normal limits. Pelvis (anteroposterior (AP)) and left hip ) Plain radiographs were taken, and they showed a left neck femur fracture with an osteolytic lesion at the fracture line. There were multiple osteolytic lesions seen in the left acetabulum and right hip. Additionally, there was generalized osteopenia and protrusio acetabuli on the left side  evaluation showed the presence of osteoporosis.The diagnosis of primary hyperparathyroidism with a right parathyroid adenoma was established. After determining that the patient had osteolysis, intravenous fluids, a loop diuretic, and vitamin D3 were administered to the patient.Blood investigations  were taken daily to monitor corrected calcium levels. On the third day of admission, the correct calcium level was average, 2.3 mm/l. Right parathyroidectomy was done to treat the primary cause, and the parathyroid hormone level dropped by more than 50% immediately post-excision. The histopathology laboratory reported no malignant cells to be found. On day one postoperatively, the patient developed “hungry bone” syndrome, with the crisis manifesting as muscle spasms, numbness, and tingling in the hands, feet, and face, requiring calcium and vitamin D treatment. The patient was treated accordingly.Day three postoperatively normalized his parathyroid hormone and corrected his calcium level. Then, the patient was taken to the operation room by an orthopedic surgeon for a bone biopsy from the distal left femur and sent to a histopathology laboratory for a frozen section diagnosis. It came as bone marrow elements with focal hemosiderin deposits and fibrosis, consistent with a diagnosis of the brown tumor. Due to the patient Mirels’ score of 10, the operation proceeded to close reduction and cephalomedullary nail (reconstruction nail) for the left neck of femur fracture and prophylactic fixation for the right hip by proximal femoral nail (PFNA) Figure .Postoperatively, the patient started to mobilize non-weight-bearing (wheelchair). The patient was discharged on oral calcium, a vitamin D supplement, and regular follow-up in the outpatient department with the endocrine clinic and orthopedic clinic.Brown tumors of the bones are a late manifestation of severe hyperparathyroidism and primarily affect the cortical bones. Microhemorrhages and microfractures characterize it, leading blood products like hemosiderin to deposit and become reddish-brown, hence the tumor name ,6. The cBrown tumors are more common in females, with a female-to-male ratio of 5:434200405; they are also more common in older age groups, usually in the 50s and 60s ,17. MultThis article is a case report explaining the occurrence of a brown tumor in a young male with primary hyperparathyroidism. A brown tumor is a benign intraosseous tumor caused by osteoclast hyperactivity. It is a rare tumor with an incidence of 3%. It is more common in females and older age groups and uncommon in long bones. This case demonstrates a young male patient who presented with a pathological fracture in the femur and was initially diagnosed with hyperparathyroidism due to the presence of an adenoma. Moreover, on further investigations after parathyroidectomy, we found multiple brown tumors with multiple osteolytic lesions and increased levels of calcium and PTH. We performed a right parathyroidectomy, a closed reduction, a cephalomedullary nail (reconstruction nail) for the left neck of the femur fracture, and prophylactic fixation for the right hip with a proximal femoral nail to our patient. He will receive regular follow-ups to track the disease’s further development. Finally, every physician needs to have a high clinical suspicion of primary hyperparathyroidism innovation, who presented with osteolytic lesions, with respect to the patient’s age and gender.


We discuss the radiological-pathological aspects of a rare case of transformation of a presumed fibroadenoma (FA) to a malignant phyllodes tumor (PT) and review the literature. Phyllodes tumors often show heterogeneous histologic features with some areas indistinguishable on core needle biopsy. A core biopsy is often a small representation of a larger lesion. As such, a complete excisional biopsy is often needed for a definitive pathologic diagnosis. Careful clinical and imaging correlation and follow-up are necessary, even in a benign fibroepithelial lesion (FEL). Fibroepithelial lesions (FELs) range from benign to malignant neoplasms that present with varying degrees of stromal proliferation compared to epithelial components . FibroepPhyllodes tumors comprise <0.5% of all breast malignancies . They tyThe literature has shown that it is very difficult to distinguish between phyllodes tumors and other benign or malignant tumors of the breast based on imaging and pathology. We document an unusual case of transformation of a presumed fibroadenoma to malignant phyllodes. We discuss the literature surrounding the fibroadenoma-phyllodes relationship, addressing imaging features and limitations of pathology.A post-menopausal female in her sixth decade presented with a new, nonpalpable left breast nodule on a screening mammogram. Ultrasound showed a 1 cm smooth hypoechoic nodule , the nodule grew to 2.6 × 1.7 × 2.8 cm, changing from smooth and homogeneous to lobulated and heterogeneous  staging was pT1NxMx. The patient was referred to radiation oncology for consultation and consideration of adjuvant radiation therapy to decrease her risk of local recurrence. She was treated with six weeks of 60 Gy adjuvant radiation therapy. Her clinical breast exam was normal after adjuvant therapy, and follow-up breast imaging was benign. The patient remains clinically and radiographically with no evidence of disease for >1 year and is followed by her oncology team every six months with annual CT chest and laboratory exams.Fibroepithelial lesions (FELs) encompass a spectrum of histologic findings, ranging from fibroadenoma to malignant phyllodes that can appear similar radiographically. Cellular fibroadenoma, benign phyllodes, and borderline phyllodes lie along the continuum that progresses from fibroadenoma to malignant phyllodes. Cellular FAs reside on the cusp of PT within a grey area along this continuum. Cellular fibroadenoma often requires excision based on size or inability to distinguish CNB from more aggressive fibroepithelial lesions, such as PT. The difference in surgical management is that benign FELs (FAs are included in this) are typically managed surgically by enucleation only, whereas only FELs with malignant potential  require local excision. Increased stromal cellularity, stromal mitosis, stromal overgrowth, fragmentation, nuclear pleomorphism, and infiltrative borders are associated with the upgrade at surgery . These wPT occurs at an older age than FA, and in one study, the median age of occurrence for PT and FA was reported to be 39 and 23, respectively. Hence our patient’s age would favor PT . Lesion Apart from sampling error, breast pathologists demonstrate low agreement, achieving 100% agreement in only two out of 21 cases . The agrWhile cases of transformation of FA to PT are rare, identical somatic MED12 mutations and clonal relatedness analysis in FA and PT in the same patient support the hypothesis that a subset of FA are clonal, neoplastic, and can progress to benign/malignant PT ,18.A report of a patient with a 9 mm nodule showed FA at CNB with five years of mammographic stability. However, in the sixth year, the mass grew to 4 × 3 cm and surgery revealed malignant PT .Another report of a 40-year-old woman revealed fibroadenoma at core biopsy, which doubled in size in the fourth year of follow-up and was diagnosed as malignant PT at excision . At yearIn summary, we document a rare occurrence of transition from a histologically benign, imaging stable FEL to a malignant PT, highlighting some of the challenges in the management and diagnosis of these lesions. As seen in our case and reviewed in the literature, an initial biopsy can be limiting due to the heterogenous nature of PTs and their ability to resemble benign FAs. Relative stable imaging characteristics for significant periods of time before evidence of transformation to a more malignant-appearing nodule confounds radiologists. While some evidence has shown that interval growth and older age should trigger consideration for excision, which is required for definitive diagnosis, there is no definitive mechanism to distinguish between these two fibroepithelial lesions before significant evidence of change on imaging leads to a high clinical suspicion, especially in the setting of a previous CNB that showed a benign lesion. Our case highlights the importance in closely analyzing these cases, especially in older populations with some interval growth, to ensure the correct diagnosis and treatment of these patients.


The case report describes a 73-year-old woman, with a history of diabetes, who presented with left hypochondrium pain. Interrogation revealed a long-term history of living with Echinococcus granulosus endemic area, associated to close contact with sheep and dogs. Upon physical examination, a painless mass of the left hypochondrium, fixed to the deep plane. Abdominal ultrasonography (USG) showed a 9 cm encapsulated mass in contact with the tail of the pancreas. Further investigation was carried out by performing an abdominal computed tomography (CT) scan showing: large cystic mass with a partially calcified thickened wall, containing multiple vesicles, measuring 11.5 cm, located at the tail of the pancreas. The patient was put under Albendazole for a week and then operated on. During laparotomy, a hydatid cyst was located in the tail of the pancreas. Conservative treatment was done sparing the healthy pancreatic parenchyma and avoiding major surgery for a diabetic patient. Echinococcus granulosus. It is a frequent cosmopolitan parasitosis, especially in breeding areas. In Tunisia, it is rampant in a hyper-endemic mode and represents a major public health problem because of its high prevalence, the seriousness of its complications, and the significant economic losses it generates. For Hydatic cysts, the main localization is hepatic followed by pulmonary [The hydatid cyst is a metacestode caused by the development in humans and many wild or domestic mammals of the larval form of a small dog taenia: ulmonary , but in Patient information: a 73-year-old woman, with a history of diabetes, presented to our outpatient department for left hypochondrium pain evolving for two weeks, without pruritus, jaundice, or other associated signs. Interrogation revealed a long-term history of living in E. Granulosus endemic, associated with close contact with sheep and dogs.Clinical findings: upon physical examination, a painless mass of the left hypochondrium, fixed to the deep plane, with no local inflammatory signs.Diagnostic assessment: laboratory tests were within normal limits, especially with no eosinophilia. Serological tests were not performed for logistic reasons. Abdominal ultrasonography (USG) showed a 9-cm encapsulated mass in contact with the tail of the pancreas. Further investigation was carried out by performing an abdominal computed tomography (CT) scan showing: large cystic mass with a partially calcified thickened wall, containing multiple vesicles, measuring 11.5 cm, located in the tail of the pancreas  of the pancreas is a rare entity, accounting only for 0.1 to 2% of systemic echinococcosis [barriers . Other rbarriers . Lymphatbarriers . Primarybarriers . Hydaticbarriers . UltrasoCystadenoma and cystadenocarcinoma are distinguished from a CE 2 hydatid cyst by the enhancement of the edges and intra-cystic septa, after injection of contrast product. In the elderly, intraductal papillary mucinous neoplasms can take the same semiology as the hydatid cyst. The T2 sequences on MRI, the most sensitive examination, allow the differential diagnosis to be made. Other radiological signs can help to make the diagnosis of a pancreatic hydatid cyst: the presence of daughter cysts, an appearance of membrane detachment (water lily sign), or another abdominal or pulmonary hydatid location ,9. The pWe presented a compelling case of a pancreatic tail hydatid cyst, emphasizing the significance of conservative management in a patient with concomitant diabetes. Within this specific context, adopting a conservative approach becomes paramount whenever feasible. However, arriving at this decision is often fraught with challenges due to the potential resemblance of hydatid disease to other malignant lesions, such as mucinous cystadenomas of the pancreas, which commonly manifest in this anatomical region.


This is a descriptive summary of the case of a patient with Axenfeld-Rieger syndrome associated with a congenital malformation of the iris and consequent pupillary morphological alteration of an atypical characteristic reported. This anomaly is unique in scientific literature and exhibits a peculiarity that we have called pseudoacorea: Hidden pupil. Other associated abnormal clinical findings were posterior embryotoxon, astigmatism, amblyopia, and exotropia. Diagnosis was achieved by instilling ocular mydriatics into the cul-de-sac that revealed this peculiarity. It is necessary to make a differential diagnosis with other pupillary pathologies such as corectopia, acorea and microcoria. Early detection of pathology and surgical management is necessary, since it would lead to a better visual prognosis for both amblyopia and strabismus.Among the malformations of the pupil, we can find polycoria (more than one pupil), dyscoria , corectopia  and acorea (absence of pupil). In addition, morphologically normal pupils can denote other anomalies such as the microcoria described by Holth in 1923. Acorea is a rare anomaly, congenital or acquired, characterized by an absolute absence of the pupil both at rest and in mydriasis. In our case we prefer to differentiate it and name it pseudoacorea, since although there is a total absence of the pupil at rest thanks to the application of ocular mydriatics, a micropupil with discoric and corectopic characteristics is achieved. It is worth noting that we have not detected in the scientific literature any case described as the one that we will develop here.The case of a patient with Axenfeld-Rieger syndrome associated with a congenital malformation of the iris and consequent atypical pupillary morphological alteration is presented. This anomaly is unique in the scientific literature and presents a peculiarity that we have called pseudoacorea: Hidden pupil. Early detection of pathology and surgical management is necessary, since it would lead to a better visual prognosis for both amblyopia and strabismus. A 28-years old female Argentinian patient, and with Axenfeld-Rieger syndrome, who attended the ophthalmologic consultation reporting never having had a pupil in her right eye (RE), evident when looking in the mirror, and her left eye (LE) being of a normal appearance. As a personal history, she reported a phototherapy treatment resulting from neonatal jaundice as well as isolated episodes of seizures associated with febrile symptoms. She did not present a hereditary family history of any kind. At the time of the consultation, she expressed deep concern about her personal aesthetics as a result of her absence of pupils, a situation that brought her to a hospital ophthalmologic service where they tried to perform a laser pupilloplasty on her that was ineffective. The visual acuity test using the Snellen chart for distant vision showed only light vision in her RE, and 20/20 for her LE. Strabismus examination revealed a slight exotropia. On slit-lamp biomicroscopy examination of the RE, the peripheral cornea exhibited a whitish, arcuate, and concentric ridge parallel to the sclerocorneal limbus, with well-defined edges at the 6-to-12-hour temporal level that affected the entire corneal thickness, belonging to a posterior embryotoxon associated with a completely absent pupil . After tAcorea is an iris anomaly with very few cases described and is characterized by the absolute absence of the pupillary opening, unlike pseudoacorea where the absence is relative, that is, “the pupil is hidden” ,2. Irido


Spontaneous rupture of the renal pelvis (SRRP) with urine extravasation is rare. This condition is primarily associated with an obstructing ureteric calculus. It creates a diagnostic dilemma, especially when the clinical diagnosis can be inconsistent. Herein, we report a 49-year-old male patient who presented with abdominal pain for the past three days and was diagnosed with acute appendicitis. A computed tomography (CT) scan revealed a right renal pelvis rupture and urinoma secondary to an obstructive 4 mm ureterovesical junction calculi. The patient was successfully treated with double-J stent placement. In conclusion, even though SRRP is rare, emergency physicians should have knowledge regarding this condition, which often presents as an abdominal condition and may be misdiagnosed as another condition requiring surgical intervention. Radiologic investigations such as CT scans are useful methods in suspected cases of this condition in order to reduce unnecessary surgical intervention. Spontaneous rupture of the renal pelvis (SRRP) and subsequently urinoma is an underreported condition in the literature and represents less than 1% of renal injuries . Urine cThe manifestation of urinoma as the first sign of obstructive uropathy is rare and can easily be misdiagnosed as another condition that requires surgical intervention ,3,4. In Patient informationA 49-year-old male came to the ED reporting right-sided lower abdominal pain that started three days ago and intensified two hours before his arrival. The pain originated at home, and there was no history of trauma. The patient experienced nausea but no signs of fever, chills, or urinary tract-associated symptoms. He had no significant past medical history and no prior or recent surgical procedures.Clinical findingsOn physical examination, he was oriented and cooperative and only had tenderness in the right iliac fossa. His vital signs were normal: blood pressure 120/80 mmHg; cardiac rate 90 beats per min; and body temperature 36.8°C. On abdominal examination, tenderness and rebound tenderness were present in the right iliac fossa. The patient was admitted for further evaluation and management with a provisional diagnosis of acute appendicitis on clinical examination.Diagnostic assessmentCreatinine and blood urea nitrogen levels were found to be normal during a laboratory evaluation. Additionally, the C-reactive protein level was 0.4mg/dL, the liver function test was within normal limits, and the total blood count revealed a hemoglobin of 13.2 grams per deciliter, total leucocyte count of 8,900 mcL, and a platelet count of 199,000; all fell within normal limits. Urine analysis was found to be normal.Plain abdominal X-ray was unremarkable, while ultrasound of the abdomen showed the right-sided dilated pelvicalyceal system, the appendix could not be visualized, and there was minimal fluid collection in the pelvis.Utilizing IV contrast dye, a computed tomography (CT) intravenous urogram scan of the pelvis and abdomen was performed for further evaluation, and it revealed a 4 mm calculus at the right vesicoureteric junction Figure  causing Diagnosis A provisional diagnosis of SRRP with urinoma was made depending on CT scan findings.Therapeutic interventionsAs a result, the patient was transferred to a urologist's care and given Inj Levofloxacin 500mg intravenously once a day, with adequate hydration as per the body weight. Due to the urinoma's small dimensions upon presentation and potential to reabsorb without surgery, the urologist decided to remove the obstruction and treat it conservatively. The patient underwent a double-J stent implantation after cystoscopy and retrograde pyelography. The pyelography showed a raw healing area of rupture Figure . The proFollow-up and outcomeThe patient was discharged on day 2 and followed up in a urology clinic. The double-J stent was removed after 21 days without complication, and the patient follows up regularly in the outpatient clinic.In the literature, SRRP is a disorder that is underreported. This is due to a number of factors such as contrast-enhanced imaging tests being not advised as the primary imaging techniques for the examination of patients with acute flank pain, and hence, clinically minor ruptures are likely to be left undiagnosed. The diagnosis of pelvic rupture and urinoma comes down in the list of differential diagnosis to be considered in case of left flank pain .An unusual manifestation of ureteral stone obstruction is renal pelvis rupture; Wunderlich was the first to report it in 1856. The same etiologies that can induce pelvic rupture also contribute to forniceal rupture, which is a more common condition that is also related to obstruction [Symptoms of pelvic rupture are similar to those of renal colic, e.g. nausea, flank pain, and vomiting. There is abdominal tenderness in physical examination, and there are signs of peritonitis; hence inflammatory conditions are to be primarily considered as differential diagnoses, e.g. appendicitis and cholecystitis ,6.SRRP is very unusual. The most often documented causes of rupture of the renal pelvis are stones, pregnancy, renal transplants, vesicoureteral reflux, iatrogenic trauma, ruptured renal cysts, tumors, strictures, retroperitoneal fibrosis, post-radiation scarring, retroperitoneal fibrosis, and urinary tract infections .The literature underreports SRRP associated with distal ureteral stone. Ninety percent of 2-4 mm ureteral stones treated with observation therapy may pass on their own after 40 days. Fifty percent of stones larger than 5 mm may require treatment. In medical expulsive treatments in cases of distal ureteral stones with median sizes of 4.7-6.7 mm, 80% of the passage rate has been reported [Urinoma, development of perinephric or retroperitoneal abscesses, and urosepsis are only a few of the catastrophic consequences that can result from spontaneous ureteral perforation ,9. So spUrinomas can be unilateral or involve both sides. Symptoms experienced by the patient can be due to encapsulated or confined collection. Primitively, researchers believed urinoma could possibly protect renal function. Recent studies, however, cast doubt on the protective effect of urinomas because some patients have reported a decreased renal function in the kidney on the same side  as the urinoma. Urinomas can be obstructive or non-obstructive .The causes of urinoma can be obstructive, such as pregnancy, pelvic masses, enlarged prostate, ureteral stones, enlarged lymphatic glands, post-radiation scarring, retroperitoneal fibrosis, congenital anomalies, and posterior urethral valves. Non-obstructive causes include injuries from genitourinary, retroperitoneal, pelvic, or gynecological surgeries, as well as kidney injuries. Urinoma is a rare disorder, often caused by trauma to the urinary tract in adults. Although urinary calculi and other obstructive conditions can lead to urinoma, they are less likely to be the direct cause. Pyelosinus backflow of urine, a condition that occurs when intrapelvic pressures exceed 35 cm H2O and the calyceal forniceal ruptures, can result in the development of urinoma. Urinary extravasation is present in 5% to 17% of cases of acute urinary blockage .Urine frequently leaks with extensive extravasation into the perirenal or subcapsular region within Gerota's fascia, and it may also travel through lymphatic vessels. It will travel along the iliopsoas area just below the inguinal ligament to the buttocks, thighs, scrotum, or peritoneum if it extends inferiorly. The majority of the time, urinomas are modest when they are first discovered and will go away on their own. A urological procedure is frequently needed to remove a urinoma if there is a fever, a major damage, urosepsis, or a huge expanding urinoma that may be compressing. A CT KUB without contrast that includes a low-dose non-contrast phase and a delayed image phase performed 10 minutes after giving IV contrast for confirmation and analyzing a suspected perinephric collection may be used to examine the patient after renal ultrasonography. Management of spontaneous ureteral rupture is not standardized. Excellent results are achieved with conservative treatments and minimally invasive procedures ,10.Typically, the first-line treatment involves inserting a drain under imaging guidance into the urinoma and giving empiric antibiotics. A percutaneous nephrostomy tube may be inserted by the surgeon to improve drainage if the drain is unable to remove the urinoma as it should. A ureteral stent accelerates healing. In severe cases, surgery is performed. The best way to prevent extensive procedures is through early diagnosis and rapid treatment .Only a tiny calculus, measuring 4 mm in diameter, was visible in our patient. Additionally, he had no prior trauma, so we had no reason to believe that his ureter would have ruptured. Although spontaneous ureteral rupture is a rare consequence of urolithiasis, when the calculi are tiny (<5 mm), it should still be taken into consideration as a differential diagnosis in emergency patients who have flank pain or pain in the right iliac fossa.Even though SRRP is rare, emergency physicians should have knowledge regarding this condition, which often presents as an abdominal condition and may be misdiagnosed as another condition requiring surgical intervention. Radiologic investigations such as CT scan are useful methods in suspected cases of this condition in order to reduce unnecessary surgical intervention. Conservative treatments, along with drainage techniques, may help to prevent further complications.


Prostate cancer is the most common malignant tumor in men. The vast majority of prostate tumors are represented by prostatic adenocarcinomas (up to 95%). Sarcoma is a very rare tumor in adults with a formidable prognosis. Early diagnosis and radical surgery offer patients the best chance of a cure.We report the case of a 44-year-old patient with stage VI unresectable high-grade undifferentiated prostate sarcoma, initially presenting with urinary disorders and a large pelvic mass of prostatic origin, with normal Prostate-specific antigen (PSA) levels. The patient was managed by palliative chemotherapy. Sarcoma represents less than 0.1% of primary prostate cancers . The oriThe patient was a 44-year-old man with no prior medical history, who reported urinary disorders (pollakiuria and urge incontinence) and nonspecific abdominal pain for the past four months, evolving in the context of general malaise. Physical examination was unremarkable, save that a digital rectal examination (DRE) revealed an enormous asymmetric prostate gland with a hard mass. During a urology consultation, an abdominal-pelvic ultrasound revealed a huge pelvic mass most likely developed at the expense of the prostate, with left ureterohydronephrosis due to trigonal invasion Figure .Laboratory tests revealed a Prostate-specific Antigen (PSA) level of 0.93 ng/mL, carcinoembryonic antigen level of 0.5 ng/mL, carbohydrate antigen 19-9 level of 3.8 U/mL, and C-reactive protein level of 7.5 mg/L.Thoraco-abdominal-pelvic CT scan showed a huge prostatic mass with prostatovesical and prostatorectal shielding and left ureterohydronephrosis. It also showed a nodule in the pelvic peritoneum and ilio-obturator lymphadenopathies Figure .A pelvic magnetic resonance imaging (MRI) was also performed and revealed a large pelvic tumor mass associated with a solid mass in contact with the left colon, causing left ureterohydronephrosis and external iliac vein thrombosis Figure .A transrectal prostate biopsy was performed, and the histopathological examination showed a poorly differentiated malignant tumor proliferation. Immunohistochemistry revealed anti-AML ( actine muscle lisse) antibodies with a proliferation index of 80%, concluding that it was a high grade undifferentiated sarcoma Table .2 over three days every three weeks was made. A few days later, the patient died of post-chemotherapy tumor lysis syndrome.The case was discussed in a multidisciplinary meeting, and the decision was made to put the patient on palliative chemotherapy, a monotherapy based on fractionated doxorubicin 60 mg/mProstate cancer is the most common cancer in men over the age of 50 and is the leading cause of cancer mortality in men over 70 years old . HoweverClinically, revealing symptoms are irritative lower urinary tract signs, as in our patient, hematuria, dysuria, or acute urinary retention. In 25% of cases, the diagnosis is made at the metastatic stage . TypicalLaboratory tests (circulating tumor markers) have no specificity, and prostate-specific antigen is usually normal except in carcinosarcomas. Imaging assesses local, regional, or metastatic extension. It includes transabdominal ultrasound and transrectal ultrasound for biopsies. It shows an increase in prostate volume with irregular contours.Thoraco-abdominal-pelvic CT scan is the key examination for assessing local and regional extension and distant metastases. It usually shows a large solid mass with well or poorly-defined margins with heterogeneous or delayed enhancement, delimiting necrotic-cystic areas . Pelvic The diagnosis of prostatic sarcoma is obtained by histopathological and immunohistochemical studies, usually following a transrectal biopsy or transurethral resection . It conf2 over three days was decided, but it was poorly tolerated.The treatment of prostatic sarcoma is not yet standardized and involves a multidisciplinary approach, including surgery, pre or post-operative radiotherapy, and neoadjuvant or adjuvant chemotherapy. The choice of treatment depends on various factors, such as the patient's age, histologic type, grade, tumor stage, and the extent of the disease. Polychemotherapy based on anthracyclines is often prescribed, and some phase II randomized clinical trials have shown the benefits of drugs like pazopanib, regorafenib, nivolumab, and imatinib in terms of progression-free survival ,11. In oThe prognosis of prostatic sarcoma is poor, with reduced survival regardless of surgery . In a muAdult prostatic sarcoma is a rare tumor that forms a heterogeneous group of highly malignant tumors with negative PSA (Prostate-specific antigen) and is often diagnosed late. Morphological examination coupled with immunohistochemical studies is key to its diagnosis, while imaging is essential for assessing its extent and post-therapeutic follow-up. Its treatment is not yet standardized, and its prognosis remains poor.


Acute appendicitis is the leading cause of emergency pediatric surgical admissions in the world. The diagnosis is may be difficult and is often dependent on clinical parameters. This study was aimed at reviewing the clinical presentations, the management and outcomes in children with inflamed and phlegmonous appendicitis with reference to the operative findings.p < 0.05 considered statistically significant.The records of 211 children 5 to 15 years of age who were operated for acute appendicitis with intra operative findings of inflamed or phlegmonous appendicitis who met inclusion criteria were entered and analyzed using SPSS (IBM) V.26. Descriptive and regression tests were done with p = 0.77).Of 211 children with inflamed and phlegmonous appendicitis, the M: F was 1.48:1 with a median age of 11 years. 58.3% of them presented within 24 h with the commonest symptoms being right lower abdominal pain, anorexia, and vomiting  respectively. 96.7% of them had right lower abdominal tenderness. 73% had neutrophils ≥ 75%, and of 171 patients who had abdominal ultrasound scan, 97.7% showed appendiceal diameter ≥ 6 mm. Intraoperatively 56.4% of them were found to have phlegmonous appendicitis. In a retrospective Pediatric Appendiceal Score, only 52.6% of patients fall into the high-risk category, who could be confirmed on preoperative clinical assessment. Postoperatively 90% of them discharged improved with a mean hospital stay of 2.26(SD = 0.9) days. There was no association between the sex of the child and the intraoperative finding of inflamed or phlegmonous appendicitis (Pediatric appendicitis affects more male children in their second decade of life. Most had phlegmonous appendicitis and presented within 24 h. Duration of illness has little effect on the progress of appendicitis. Surgical management is safe for inflamed and phlegmonous appendicitis with a reasonable hospital stay and a low rate of complications. Acute appendicitis is the leading cause of surgical emergency admissions in the world , 2 and tA correct and timely diagnosis of acute appendicitis is very important in reducing the complications and negative appendectomy rates, for this reason several diagnostic scores have been introduced in the last few decades but none has gained wide acceptance because of variability of the outcomes . The diaOf the scoring systems proposed to evaluate appendicitis in children presenting with acute abdominal pain, Pediatric Appendicitis Score (PAS) and Alvarado scores are relatively regarded as better tools to use as a guide to assist in the decision of the management of a child with abdominal pain , 8.Even if recent evidence recommends medical management as an alternative treatment of patients who have clinical and imaging diagnosis of localized appendicitis, appendectomy remains the mainstay of treatment for uncomplicated appendicitis to prevent further complications , 10.There are variable study findings worldwide in the presentation, diagnosis, management and out come of appendicitis , 12. TheN = 416) 5 to 15 years of age who underwent appendectomy between January 1st,2018 to December 31st, 2020 at Tikur Anbesa Specialized Hospital and its affiliate Menelik-II Specialized Hospital, where fulltime surgical service is given by Pediatric surgery residents, Fellows, and Consultants.It is a retrospective cohort institution-based study conducted on all children (hyperemic and or swollen appendix without mass formation) or phlegmon . Histologic finding was not included in the study as it was done only for few children with specific indications.After Checklist was prepared and medical records examined, data were coded and entered into SPSS(IBM) V. 26 based on required baseline information on demography, pre-hospital duration of illness, admission date, all presenting symptoms, admission physical examination findings, preoperative laboratory and ultrasound results, intraoperative findings, pre and postoperative management and post-operative course including the overall hospital stay. The findings also summed up for PAS and Alvarado scores. The type of appendicitis was sorted based on the intra-operative description of the appendix with signs of inflamed appendix  V.26 Windows software. Descriptive analysis was performed on demographic variables and logistic regression to assess the odds ratio based on characteristics of the variables, and the confidence interval of statistical associations to determine the association between dependent and independent variables, Value of A total of 416 children, between the ages of 5 to 15 years, were operated on for all types of acute appendicitis. Those with inflamed and phlegmonous appendicitis account for 286(68.8%) of whom 211 met the inclusion criteria for analysis. Of the 211 cases selected 126(59.7%) were male with M: F of 1.48:1, and median age of 11 years. The mean duration of illness was 29.4 h with the common presenting symptoms reported of right lower abdominal pain in 203(96.2%) with an associated shift of abdominal pain in 73% of cases and vomiting in 85.3% of cases. A significant number of them (96.2%) presented with loss of appetite and 52.6% of them reported low-grade fever  were found to have some degree of right lower quadrant tenderness  showed temperature records of less than 37.2 3 with a mean count of 12,918/mm3 and 154(73%) had Neutrophils ≥ 75% with a mean of 78.6%. Of 171 patients whose Ultrasound records were examined 167(97.7%) had appendiceal size greater than 6 mm and a mean of 8.3 mm.Seventy-one percent of them were recorded to have a WBC count of more than 10,000/mmOpen appendectomy was done for all cases with finding of 56.4% phlegmonous and 43.6% inflamed appendicitis. The appendix was located in 104(49.3%) retro cecal with 67(31.7%) of them sub-Cecal and the rest in the pelvic, pre-ileal, and sub-hepatic positions.Postoperatively 205(97.1%) of them took antibiotics during their hospital stay and only 33.6% of them were given oral antibiotics upon discharge and the average hospital stay was 2.6 days (SD 0. 917). The postoperative course for most of them (90%) was uneventful and most of them were followed up for one month, with only 21(10%) developing minor wound complications and other problems related to neither the disease process nor the management of appendicitis.Of the 211 patients' records computed 52.2% fall in high-risk category for PAS and 40.3% for Alvarado with a mean score of 7.4(SD = 1.920) and 7.66(SD = 1.92) respectively . The sensitivity of the model in predicting intraoperative findings inflamed or phlegmonous appendicitis was high indicating most of them could be predicted by preoperative assessment. The likelihood of making inflamed or phlegmonous appendicitis within 48 h of illness was high for right lower quadrant abdominal tenderness, Anorexia, vomiting, the shift of pain, admission temperature record of > 37.2 0C, and sex of the patient .Prediction of the inflamed appendix is significantly noticed in those who presented with a duration of less than 24 h, vomiting, and Neutrophil < 75% with Even though several studies have been conducted regarding the general knowledge of acute appendicitis, only few studies have been done relating intraoperative findings with clinical parameters and the contribution of individual parameters in the prediction and diagnosis of inflamed and phlegmonous appendicitis.3, neutrophil percentage of ≥ 75%, and Ultrasound appendiceal diameter of ≥ 6 mm, indicating a higher predictive ability of these parameters in the diagnosis of inflamed or phlegmonous appendicitis, whereas the changes in the vital signs were unremarkable showing little contribution in the prediction of the likelihood of the two forms of acute appendicitis. Though most presented within 24 h, in contrast to the general belief that phlegmon is a late process of early appendicitis, there was a higher number of phlegmonous appendicitis implying delay in diagnosis of more than 24 h might carry a potential risk of complications. Regarding appendiceal scoring systems, relatively a higher number of retrospectively assessed PAS group were in the high-risk category, making it the better scoring system as compared to Alvarado in the diagnosis of children with inflamed or phlegmonous appendicitis. The Post-operative course in the study cases was uneventful for most and discharged improved with a reasonable hospital stay, denoting open surgical management is still a viable mode of intervention in the developing world where there is no luxury of laparoscopic and medical management.The study found that there is slight male predominance mostly affecting children around eleven years and most of them presented with right lower abdominal pain, the shift of pain, vomiting, loss of appetite, and low-grade fever. Variable degree of right lower quadrant abdominal tenderness was the predominant finding and a significant number of patients demonstrated a WBC count above 10,000/mmOf the 211 pediatric patients operated for inflamed and phlegmonous appendicitis 59.7% were male with a M:F ratio of 1.48 similar to other studies , 14 and The mean duration of illness was 29.4 h, comparable with other studies , 19. 96.3 (SD = 4000) in inflamed appendicitis [According to Samuel M., the Mean white blood cell count was 13.5 × 10ndicitis , and in ndicitis  which isIn a retrospectively assessed PAS, only 52.2% were at high risk with a mean score of 7.4 (SD = 1.920) which is higher than other studies with a PAS mean of 5.8 (SD = 1.4) , and in Literature is lacking on the intraoperative patterns of inflamed vs phlegmonous appendicitis. In this study, there were 56.7% found to have phlegmonous appendicitis with the majority (58.3%) presented within 24 h which is against the common belief that phlegmon is a late event in the early stage of appendicitis. Regarding intra-operative positions of the appendix nearly half of them were retro-Cecal which were completely different from figures in the literature .Postoperatively 97.1% of them took antibiotics during their hospital stay with a reasonable hospital stay of 2.6 days (SD = 0. 917). The postoperative course for the majority of them (90%) was uneventful with no recorded mortality and the rest with minor wound infections and complications unrelated to appendicitis, indicating surgical management is still a viable option for patients with acute inflamed and phlegmonous appendicitis.The variabilities in the findings among different assessment methods in the prediction of inflamed or phlegmonous appendicitis are the results of underemphasis of the relative contributions of clinical symptoms and signs. Right lower abdominal pain with any degree of tenderness, anorexia, vomiting and nausea predicted well the occurrence of acute inflamed and phlegmonous appendicitis and duration of illness may not be the major factor in the progression of appendicitis. Some clinical variables, like anorexia, were understated in many studies despite their occurrence in a significant proportion. Surgical management remains a viable option of management for Paediatric acute appendicitis with reasonable hospital stays and a low rate of complications.It is a retrospective study with missing data for some of the variables limiting its clinical applicability and needs to be conducted on a larger scale.


Even though urolithiasis in general is not uncommon, urethral stones have an incidence of less than 0.3% and are 20 times less common in children. Though cases of urethral stones have been reported in children from endemic areas, they are even rarer in countries like Uganda that are not endemic for urolithiasis.The authors present a 7-year-old male who presented with acute urine retention. Though the diagnosis of retention was made in a lower-level health facility, the cause of the retention was not determined till the patient arrived at a general hospital. Diagnosis of an obstructing stone in the penile urethra was made clinically. Meatotomy and stone extraction were done, and a urethral catheter was passed.When attending to children with acute urine retention, urolithiasis should be kept among the differential diagnoses, even in areas that are not endemic for urinary tract stones. A thorough clinical evaluation may be all that is needed to make a diagnosis. HighlightsUrethral urolithiasis can present as acute urine retention, even in children.In areas not endemic for urinary tract stones, a high index of suspicion is necessary to make the diagnosis.A thorough clinical evaluation may be all that is needed to make a diagnosis.Even though urinary tract stones are a relatively common problem, urethral stones are a rare type of urolithiasis, accounting for ~1% of all presentationsUrinary tract stones have been reported to have a geographical pattern, and paediatric urolithiasis is said to be more common in places along the ‘stone belt’ that runs from the Philippines, Thailand, and Myanmar in the Far East through Pakistan into Iran, Middle East and extending up to TurkeyWe present a 7-year-old male who had been completely well until 2 days prior to the presentation. He presented with a history of inability to pass urine, associated with lower abdominal pain, penile pain when attempting to pass urine, and dribbling. The mother reported no history of such symptoms in the past, and there was no significant medical or family history. Prior to presentation, the child had been managed in a peripheral lower-level health facility, where suprapubic aspiration of urine was done to temporarily relieve the abdominal pain given that urethral catheterisation had failed. The underlying cause was not ascertained at the lower-level health facility, and the failure to pass urine persisted, resulting in a referral to a general hospital for further evaluation and management.On examination, he was alert, with a tachycardia of 90 beats per minute and dry mucous membranes, but the rest of the vital signs were in the normal range. On abdominal examination, we noted a distention in the suprapubic region that was dull on percussion. While attempting to pass a urethral catheter, we noted that there was a whitish mass at the urethral meatus that was hard on palpation and could not be expressed out through the meatus. A working diagnosis of acute urine retention due to an obstructing stone in the urethral meatus was made. Under sedation, a stone measuring 11 by 7 mm Fig. .After relieving the urine retention, urinalysis revealed the presence of gram-negative rods, the complete blood count was unremarkable, and erythrocyte sedimentation rate was 29.4 mm/h and an abdominal radiography did not show any other stones in the urinary tract. Ultrasonography did not reveal any anatomical abnormalities. The patient was rehydrated, and oral cephalexin plus paracetamol were administered for 5 days. The catheter was removed on the fifth day, and the child was discharged with advice on adequate fluid intake. For the 2 months of follow-up at the general hospital, the child was well, and the mother reported no symptoms related to urolithiasis.A urethral stone can lodge at any point of the urethraPatients usually present with dysuria or acute urine retention with a palpable stone in the external meatus or in the penile part of urethraThe management options for urethral stones are variable and depend largely on various factors like the location of stone impaction, the size of the stone, and the presence or absence of any associated urethral pathologies. Retrograde manipulation of the stones back into the urinary bladder may be suitable in patients with small urethral stones, followed by litholapaxy or lithotripsyEven in areas like western Uganda that are not endemic for urolithiasis, when children present with acute urine retention, the attending clinician needs to keep urinary tract stones on the list of possible causes. More so, examination of the urethra should not be ignored since this can help in making a diagnosis and giving definitive care. When attempts to pass a urethral catheter are futile, thorough examination of the urethra by palpation may help to find the stone.Clinicians attending to children presenting with acute urine retention need to keep in mind that the cause could be urolithiasis, even in regions that are not endemic for urinary tract stones. A thorough examination of the urethra may be all that is required to make the diagnosis.Not applicable.We obtained written informed consent from the mother of the child for the publication of the case report and the images. A copy of the consent is available for review by the editor in chief of this journal on request.This case report did not receive any specific grant from funding agencies in public, commercial, or not for profit sectors.J.M. managed the patient and wrote the first draft. B.M. and S.B. were involved in patient management, review and editing of the manuscript. D.K., S.M.K., and S.F.M. reviewed and edited the manuscript. All authors approved the final version of the manuscript submitted.None.Name of the registry: not applicable.Unique identifying number or registration ID: not applicable.Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicableJoshua Muhumuza.Not commissioned, externally peer-reviewed.


Rupture of the renal collecting system is a rare event, usually occurring at the ureterovesical junction (UVJ). The most common cause is nephrolithiasis, usually directly correlated with the size of the stone. Other causes include bladder outlet obstruction, ureteropelvic junction obstruction, and extrinsic ureteral compression by a malignant pathology. The mechanism is increased pressure within the collecting system, and symptoms vary from vague mild abdominal pain to severe excruciating pain. We present a case of a 19-year-old female with obstructive uropathy and renal calyceal rupture caused by a 3 mm stone at the UVJ. Due to the small size of the stone and her hemodynamic stability, she was treated conservatively with tamsulosin and IV ceftriaxone. The following day she passed sediment in the urine and noted pain improvement. Calyceal rupture with small stones is exceedingly rare, may be missed on a CT without contrast, and should be suspected when perinephric edema or fluid is seen. This is the smallest recorded stone causing calyceal rupture to the best of our knowledge. CT with contrast is indicated for diagnosis when calyceal rupture is suspected and is suggested by extravasation of contrast. Early diagnosis and intervention, in collaboration with urologists, can help to avoid long-term complications such as acute kidney injury, urosepsis, and urinoma. Conservative management may still be considered after a calyceal rupture in patients with small, potentially passable stones. However, if there is associated obstructive uropathy, infection, or significant rupture, then stenting may be indicated. This case highlights the diagnosis of calyceal rupture in the setting of tiny stones and the efficacy of conservative therapy versus early stenting in the management of stable patients. Renal colic is a common cause of presentation to the emergency department, with an estimated prevalence of 10% to 15% of the United States population and resulting in over 1.3 million visits to the emergency department annually . Risk faAcute renal colic management has three components: pain management, treating the cause, and managing complications. CT scan without contrast is the modality of choice to diagnose kidney stones; however, this case illustrates a rare complication of a small stone where a contrast study is indicated to clarify the diagnosis of calyceal rupture, 74% of which are related to obstructing stones [3 with 71.4% neutrophils. Computed tomography of the abdomen and pelvis with contrast showed a 3 mm calculus at the ureterovesical junction with mild to moderate right hydroureteronephrosis and edema adjacent to the right kidney  30-50/HPF, RBC 3-5/HPF, blood - large, bacteria - rare, leukocyte esterase - small, and nitrite was negative. A pregnancy test was negative, serum WBC 13,200 m/mmShe was treated conservatively with IV fluids, intravenous ketorolac as needed, IV ceftriaxone, tamsulosin, and a urology consult was placed. The urology consultant decided to treat her conservatively as she was afebrile, hemodynamically stable, and did not meet the criteria for sepsis. Additionally, given the size of the stone being 3 mm, there was a good chance it would pass spontaneously, and she could avoid the potential risks of an invasive procedure. If she developed new symptoms, signs of infection, or the stone did not pass the next day, the consultant's initial plan was to place a ureteral stent. The patient was closely monitored, and after 36 hours, she reported passing "sediment" in her urine and experiencing significant improvement in the pain. The following day she denied any urinary symptoms, was discharged on tamsulosin, and was advised to follow up with the primary care physician and urologist as an outpatient.Renal colic usually manifests by acute unilateral abdominal pain usually associated with hematuria, nausea, and vomiting. Treatment focuses on symptomatic treatment, expulsive therapy for the stones, and managing complications, including superinfection, hydronephrosis, and rarely calyceal rupture.Pain management options include acetaminophen, IV nonsteroidal anti-inflammatory drugs (NSAIDs), or narcotics. IV NSAID is the first choice in the case of normal renal function  because Small stones of <5 mm typically pass spontaneously and so are treated conservatively with pain medications, smooth muscle relaxants like tamsulosin, and IV antibiotics if a superimposed infection is suspected.Only 60% of stones 5-7 mm pass spontaneously without any intervention .Renal calyceal rupture is a rare manifestation of stones <5 mm, as 98% of them pass spontaneously without causing obstructive uropathy .The best diagnostic study for the initial identification of kidney stones is a CT scan without contrast , especiaIndications for interventions are presenting with severe agonizing pain not adequately controlled by analgesics, increased fluid/edema around the kidney in comparison with the initial study, complicated urinoma, an acute rise in creatinine level, or superinfection . InterveCalyceal rupture is a rare but recognized complication of small kidney stones. CT with contrast is advised if perinephric edema is noted in the initial imaging study. A urology consult should be placed for possible intervention in the setting of acute kidney injury, secondary infection, urinoma formation, inadequate pain control, or increasing size of the fluid collection around the kidney. This case reviewed the diagnosis of calyceal rupture, an infrequent occurrence with small stones, and when to consider conservative management versus urgent urological consultation in order to avoid a decline in patient status.