Laparoscopic adjustable gastric banding has been the gold standard for surgical management of obesity over the last decades in USA and Europe. However, significant complications have been documented due to foreign body placement, including band erosions. Our treatment approach for erosions is rather observant with regular follow-up until the band has sufficiently perforated the gastric wall which facilitates endoscopic removal. Consequences of a not followed-up band erosion may present even after a long time following initial diagnosis with more severe complications.A 51-year-old Caucasian woman presented to our out-patients’ clinic with a 2-week history of worsening abdominal pain in her left upper quadrant, exacerbated by abdominal flexion and extension maneuvers.Here we describe a case involving gastric penetration and subsequent downward migration of a band into distal jejunum causing small bowel obstruction, which occurred more than 10 years following initial diagnosis of erosion. The perforation was missed due to cessation of endoscopic follow-up.Prospective and long-term follow-up is mandatory in those with partial band erosion to avoid further complications. At the end of the 1970s, the idea of a restrictive device to limit nutritional intake arose, with the intent of assisting in weight loss for obese patients. To this effect, Wilkinson developed a non-adjustable band that could be placed around the upper part of the stomach by open surgery ; these aAlthough preliminary studies presented promising short-term results, longer-term data are more modest, illustrating a wide variation in weight loss, with a proportion of patients being classified as treatment failures . Moreove2, and in the year 2000 for laparoscopic adjustable gastric band (LAGB) implantation. She experienced weight loss of 30 kg after her original procedure, although 3 years later a partial perforation of the band into her stomach developed . Over the subsequent years, she required serial endoscopic follow-ups until 2005 when the band was covered by the gastric mucosa only on one third of its surface. From then on and for unknown reasons the endoscopic follow-up ceased. She remained asymptomatic and regained weight up to a BMI of 36.3 kg/m2 until her current presentation.A 51-year-old Caucasian woman presented to our out-patients’ clinic with a 2-week history of worsening abdominal pain in her left upper quadrant, exacerbated by abdominal flexion and extension maneuvers. She described symptoms as intermittent, and accompanied by loss of appetite, nausea, and having a “feculent” taste in her mouth. Her previous medical history was notable for an elevated body mass index (BMI) of 41 kg/mA clinical examination revealed left-sided abdominal tenderness without signs of abdominal guarding. The blood results were unremarkable, except white blood cells (WBC) with 11.3 G/l. A plain abdominal radiograph showed signs of small bowel obstruction Fig. .Fig. 1PlAfter an unsuccessful attempt to remove the band endoscopically, our patient underwent a diagnostic laparoscopy, which showed that the gastric band was impacted in the distal jejunum causing obstruction. An enterotomy was performed via umbilical mini-laparotomy, and the partially digested silicon band was retrieved Fig. . The invHere we report a case about a gastric band migration into distal jejunum causing small bowel obstruction more than 10 years following initial diagnosis of erosion. It highlights the importance of regular endoscopic follow-ups.Gastric banding is a frequent intervention among those invested in bariatric surgery, albeit with variable long-term results. It is the least invasive bariatric surgical procedure but with a relatively high re-intervention rate . Band-reClinically, patients with gastric erosions usually complain of newly developed upper abdominal pain and an increase in weight caused by lack of satiety. Some may also present symptoms of bowel obstruction or sepsis with peritonitis. Diagnosis is usually confirmed endoscopically, and verified through cross-sectional imaging in cases of dislocation, with a quoted time-to-event ranging between 6 and 132 months , 8. The Diversity exists regarding the optimal therapy and timing of intervention. Band removal can be achieved by surgery (open or laparoscopic) or by endoscopy. In historical reports the removal of the intragastric migrated band was obtained by laparotomy followed by a gastrotomy . HoweverHowever, recent advances in endoscopic technique have allowed endoluminal division and removal of the gastric band . IntragaA rather expectative approach, which we practice in our clinic, is to wait after diagnosis until the band has sufficiently perforated (at least 50%) the gastric wall in order to facilitate removal endoscopically. The band can be cut through by endoscopic laser, scissors, metallic thread, or electrosurgical devices – to mention only a few techniques – and finally retrieved by the patient’s mouth . The forRemoval of the band without any further bariatric surgery often results in resurgence of weight gain, deterioration of physical and psychological comorbidities, and low quality of life scores . HoweverIn our case, gastroscopic removal of the band was trialed before surgery in view of the hindered situation. Unfortunately, this was not successful and for safety reasons aborted. Conversion to gastric bypass was not performed as per an advance directive provided by the patient.As a high-volume bariatric center, we present our first experience of this rare complication. The prolonged period between first diagnosis of band erosion and clinical manifestation of the meanwhile migrated band is remarkable. The cessation of periodical control gastroscopy was unfortunate, assuming that migration and consequent bowel obstruction could have been avoided by earlier removal of the band. Prospective and long-term follow-up is mandatory in those with partial band erosion, for whom regular endoscopic surveillance is advocated.


The use of point-of-care ultrasound (POCUS) by non-radiologists has dramatically increased. POCUS is completely different from the routine radiological studies. POCUS is a Physiological, On spot, extension of the Clinical examination, that is Unique, and Safe. This review aims to lay the basic principles of using POCUS in diagnosing intestinal pathologies so as to encourage acute care physicians to learn and master this important tool. It will be a useful primer for clinicians who want to introduce POCUS into their clinical practice. It will cover the basic physics, technical aspects, and simple applications including detection of free fluid, free intraperitoneal air, and bowel obstruction followed by specific POCUS findings of the most common intestinal pathologies encountered by acute care physicians including acute appendicitis, epiploic appendagitis, acute diverticulitis, pseudomembranous colitis, intestinal tuberculosis, Crohn’s disease, and colonic tumours. Deep understanding of the basic physics of ultrasound and its artefacts is the first step in mastering POCUS. This helps reaching an accurate POCUS diagnosis and avoiding its pitfalls. With increased skills, detailed and accurate POCUS findings of specific intestinal pathologies can be achieved and properly correlated with the clinical picture. We have personally experienced and enjoyed this approach to a stage that an ultrasound machine is always accompanying us in our clinical on calls and rounds. Physiological study in which the shock status can be evaluated [On spot clinical decision tool that helps in critical decision making in emergency situations within a very short time [Clinical examination and considered as the seventh sense of intra-abdominal inspection [Unique with expanding indications to study different organs in a systematic approach at the same time [Safe and repeatable and can be used exactly as a stethoscope in the hands of trained acute care physicians [Point-of-care ultrasound (POCUS) is a non-invasive diagnostic bedside tool which is fast, repeatable, accurate, and radiation-free. It is useful in critical decision-making , 2. The valuated , 7, (2) ort time , (3) it spection , (4) it ame time , and finysicians .Fig. 1MaThese significant advantages make POCUS valuable in many clinical settings including emergency departments, intensive care units, and operation theatres. With increased interest, training, and experience, POCUS will have a more pronounced role in diagnosing gastrointestinal pathology. This review aims to lay the basic principles of using POCUS in diagnosing intestinal pathologies so as to encourage residents and young colleagues to learn and master this important tool. It will cover the basic physics, technical aspects, and simple applications including detection of free fluid, free intraperitoneal air, and bowel obstruction. A more advanced and detailed review on specific intestinal pathologies will include appendicitis, epiploic appendagitis, acute diverticulitis, pseudomembranous colitis, intestinal tuberculosis, Crohn’s disease, and colonic tumours.Understanding the basic physics of ultrasound and its artefacts is essential to interpret the ultrasound images, to avoid its pitfalls, and to reach an accurate bedside diagnosis. POCUS machines send high-frequency ultrasound waves 2–15 MHz) through their piezoelectric crystals, which are located in the probes, and then receive the reflected waves , 11 3). NeverLow-frequency probes (2–5 MHz) have the stronger ability for tissue penetration while high-frequency probes 10–12 MHz) have less penetration ability but better resolution. As a result, studying deeper structures of the abdomen in obese patients  needs low-frequency probes while diagnosing superficial structures with high resolution (like acute appendicitis) needs high-frequency probes . The low MHz haveAcute care physicians use a global clinical ultrasound examination approach and may examine different anatomical regions, including the chest, abdomen, and extremities, at the same time if needed. Consequently, special considerations should be taken to observe the direction of the pointer of the ultrasound probe. It should be always directed towards the head or to the right side of the patient  Fig. 4)4). The PThe operator should have a clear mental three-dimensional anatomical map with a clear plan before performing any radiological study. This would depend on the specific clinical question and the suspected gastrointestinal pathology. For example, if the colon is going to be examined, it has to be first located and then scanned. We always try to identify the ascending colon at the right flank (as recognized by its position and haustrations) and then follow the colon all the way down to the rectum . If thatThe three “unhappy triad of intestinal ultrasound” include “too much pain, too much gas, and too much fat” . These hPOCUS can easily detect free intraperitoneal fluid with high accuracy , 20. It enhanced peritoneal stripe sign which can be changed by patient’s position (shifting phenomenon). The reverberation artefacts will hide the underlying organs. Differentiation between FIA and intraluminal gas is important. The hyperechogenic intraluminal gas of the bowel moves with respiration. However, FIA is directly located under the abdominal fascia and will not be affected by respiration [POCUS can accurately detect free intraperitoneal air (FIA) , 24. Thepiration .Fig. 5A Both linear and convex transducers can be used to detect FIA . HoweverScissor manoeuvre [anoeuvre  is applianoeuvre .Intestinal obstruction is a common gastrointestinal emergency that needs rapid and efficient management. History, physical examination, and plain radiography are essential for its diagnosis . The rolThe ultrasound examination should follow the anatomical path of the colon and small intestine. The normal bowel is seen as a circular hypoechoic structure (muscle layer) surrounding a mixture of hypoechoic (fluid), isoechoic (food), and hyperechoic contents (gas). The hypoechoic wall gets thinner during the relaxation period of peristalsis. The normal diameter of the bowel loops is up to 25 mm in the jejunum, up to 15 mm in the ileum, and up to 50 mm in the colon , 34. POCUltrasound findings of small bowel obstruction include (1) increased loop dimensions, (2) increased wall thickness (more than 3 mm), (3) increased intestinal contents, (4) increased (to and fro) or decreased peristaltic movements, (5) enlarged and visible valvulae conniventes (more than 2 mm), and (6) collapsed colonic lumen , 35 . ThIt is also important to look for the cause of obstruction at the transit point between the dilated proximal loops and collapsed distal ones. Ultrasound is capable of diagnosing several pathologies including hernias, intussusception, ascariasis, foreign bodies, and tumours . Bowel iAcute appendicitis is a common emergency pathology and may perforate in one-third of the cases if the diagnosis was delayed . MultiplThe ultrasound examination is applied in the supine position using a high-frequency linear probe. The graded compression technique is the standard technique , 41. ThiPrimary acute epiploic appendagitis is relatively uncommon. Its diagnosis and management continues to be a challenge. Depending on its anatomical site, it may mimic acute appendicitis, acute diverticulitis, or acute cholecystitis . Before The normal appendices epiploicae are not seen by abdominal ultrasound or CT unless surrounded by intraperitoneal fluid . UltrasoIn 2006, Liljegren et al. performed a systematic review comparing ultrasound, CT scan, and magnetic resonance imaging for diagnosing acute colonic diverticulitis. They concluded that ultrasound should be the method of choice for diagnosing acute diverticulitis supported by evidence at that time . In 2008A recent meta-analysis performed by Andberg et al.  has showsaw-tooth pattern  thickened wall of more than 4 mm, (2) non-compressibility and (3) loss of peristalsis , 18. Usiern Fig. . The layUltrasound is recommended as a screening tool in patients suspected to have pseumembranous colitis especially in patients who cannot be moved to the CT scan. Although the ultrasound findings in pseudomembranous colitis are not pathognomonic, their presence combined with the clinical picture should raise the suspicion of the diagnosis –59. It iClostridium difficile colitis.Ultrasound findings of pseudomembranous colitis in severe cases include a thickened colonic wall with heterogeneous echogenity and narrowing of the colonic lumen . The echIn early stages of pseudomembranous colitis, the texture of the wall of the colon is preserved. The hypoechoic oedematous mucosa and muscularis propria will be thickened. The echogenic submucosa is sandwiched between them. The submucosa may have numerous gaps indicating penetration of the infection into deeper structures Fig. . IntrapeThe differential diagnosis between intestinal tuberculosis and Crohn’s disease can be extremely difficult. Intestinal tuberculosis involves mainly the terminal ilium and caecum while Crohn’s disease involves the small bowel and ascending colon . Lim et Intestinal tuberculosis may have three forms including (1) ulcerative type, (2) hypertrophic type, and (3) ulcero-hypertrophic type , 62. IleDuring the acute phase of Crohn’s disease, the thickened submucosa of the bowel will be hyperechoic because of lymphoedema Fig.  while inCT scan is superior to ultrasound in evaluating the extent and type of abdominal tuberculosis including lymphadenopathy , 64, 66.A definite diagnosis can be reached in abdominal tuberculosis in about 80% of the patients despite every effort made. Therapeutic diagnosis should then be tried in the suspected non-conclusive remaining 20% of the cases. The majority will have a rapid response to anti-TB treatment, usually within 2 weeks . StartinMalignant colonic tumours can be either annular  or polypoid (protruding into the lumen of the colon). They may fungate either inside or outside the colonic wall. They may be large (up to 10 cm) having an irregular or lobulated contour  Fig. 1515. AnnulThe layers of the colonic wall are commonly destroyed in malignant tumours compared with diverticulitis . In inflUltrasound can miss early cancer or small tumours. Accordingly, it cannot be used as a screening tool. Nonetheless, it is useful to evaluate masses, hepatic lesions, the presence of ascites, or lymph nodes. Presence of lymph nodes has a very low sensitivity (around 30%) and a high specificity (98%) for identifying malignancy , 71.The results of POCUS depend on three factors: the operator, the ultrasound machine, and the patient. Acute care physicians should be trained and have their own proper ultrasound machines. POCUS can help clinicians improve their diagnostic skills, accuracy, confidence, and critical decision-making at the bedside . It givePOCUS is already used by various acute care physicians including surgeons, emergency physicians, and critical care physicians who have the same common language . BecausePoint-of-care ultrasound (POCUS) is an extension of the clinical examination when used by acute care clinicians in evaluating an acute abdomen. It is a unique safe diagnostic tool that can be used repeatedly on the bedside of sick patients. Deep understanding of basic physics of ultrasound and its artefacts is the first step in mastering POCUS. This helps both in reaching accurate POCUS diagnosis and avoiding its pitfalls. Detailed and accurate POCUS findings of specific intestinal pathologies can be obtained by trained acute care physicians. It is a great advantage to incorporate the POCUS findings directly with the clinical findings by the same operator so as to reach timely proper diagnosis and management.


Dear Editor,We report the case of a 24-year-old female, Fitzpatrick phototype V, referred to our Dermatology Department for an asymptomatic mass in her left dorsal region. The patient reported a slow growth of this mass over several years. Physical examination revealed a palpable, soft, subcutaneous tumor in the left dorsal region, without apparent involvement of the superjacent skin, which was painless on palpation. The remainder of the examination was otherwise normal.A high-resolution thoracic computed tomography performed one year before, in the context of an episode of asthma exacerbation, had revealed a large, low-density, subcutaneous nodularity in the referred topography A. Also, Considering this, we performed a complete surgical tumor resection, under local anesthesia, in an uneventful procedure A. The tuHibernomas are rare, benign soft-tissue tumors arising from vestigial brown fat, which can be located in the subcutaneous tissue, the skeletal muscle, or the intermuscular fascia.These lipomatous tumors generally present either as slow-growing, painless, soft, palpable and mobile masses, or as incidentalomas in imaging studies.5Histopathological examination of the tumor following complete surgical excision, which is curative, is essential for confirming the diagnosis.5Margarida Moura Valejo Coelho: Approval of the final version of the manuscript; elaboration and writing of the manuscript; obtaining, analyzing and interpreting the data; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of the case studied; critical review of the literature; critical review of the manuscript.Alexandre João: Approval of the final version of the manuscript; obtaining, analyzing and interpreting the data; intellectual participation in propaedeutic and/or therapeutic conduct of the case studied; critical review of the manuscript.Cândida Fernandes: Approval of the final version of the manuscript; obtaining, analyzing and interpreting the data; intellectual participation in propaedeutic and/or therapeutic conduct of the case studied; critical review of the manuscript.None declared.None declared.


Hepatic pseudolymphoma is a very rare benign reactive lymphoid hyperplasia associated with autoimmunity and chronic inflammatory liver diseases such as primary biliary cirrhosis and may mimic hepatocellular carcinoma. This diagnosis should be suspected in female with a suspicious single tumor. Close monitoring is needed in view of its premalignant nature. Her social and family histories were unremarkable. She had chronic rheumatoid arthritis in addition to PBC, and she was prescribed oral steroids and methotrexate. She had no abnormal physical findings.Laboratory testing was negative for hepatic virus, and hepatic function was in the normal range, although the antimitochondrial antibody titer was positive. Tumor markers, including carcinoembryonic antigen, carbohydrate antigen 19‐9, alpha‐fetoprotein (AFP), and protein induced by vitamin K absence or antagonist Ⅱ(des‐gamma‐carboxy prothrombin [PIVKA‐Ⅱ]), were within normal limits. In addition, the ICG 15 min value was 9.8% and the Child‐Pugh classification was A at 5 points , CD79a (+), CD10 (+), and Bcl‐2 (−), and the interfollicular area was CD3 (+) and CD5 (+). Taken together, a diagnosis of pseudolymphoma was favored Figure .The postoperative course was good, and she was discharged on postoperative day 7.3Pseudolymphoma, which is also termed reactive lymphoid hyperplasia or nodular lymphoid lesion, is a rare disease, especially in the liver. Based on a review of the PubMed database from 1981 to 2017 using the keywords “pseudolymphoma,” “lymphoid hyperplasia of the liver,” and “nodular lymphoid lesion,” we found 80 cases of pseudolymphomas, including our case  of HPL associated with PBC , followed by progressive bile duct loss.In contrast, PBC is rarely complicated by HCC. According to the data of all reviewed PBC patients in Japan, the incidence of HCC was 2.4%.Because the diagnosis often is established from surgery, the natural history of HPL is not well understood. Malignant conversion of pseudolymphoma has been reported in the lungs, stomach, and skin.4Hepatic pseudolymphoma should be considered when a single small tumor is found in middle‐aged females with PBC. Considering that the real nature of HPL remains unclear to date, it is necessary to follow‐up carefully.None declared.MI wrote the manuscript. MI and MT designed the study. TY, TM, MY, TI, SS, TM, WS, TS, TO, TS, YS, TH, and HT, proofread the manuscript.


IDH-mutant oligoastrocytoma with two different cell types within a single mass in a young woman is presented. Imaging findings of the left frontal infiltrating glioma predicted the two neoplastic components that were identified upon resection. Tissue examination demonstrated areas of tumor with contrasting histologic and molecular features, including specific IDH1, ATRX, TP53, TERT and CIC mutational profiles, consistent with oligodendroglioma and astrocytoma, respectively. The clinical and radiological course over 17 months from first diagnosis included three surgical resections with slow progression of the astrocytic component, and ultimately chemotherapy and radiation treatments were commenced. Reports of the clinical courses for these rare cases of dual-genotype oligoastrocytomas will inform therapy choices, to optimize benefit while minimizing side effects. The steadily increasing number of cases suggests that the neoplasm might be reconsidered as an official entity by the WHO.A case of a true dual-genotype  ATRX and TP53 variants along with 1p/19q codeletion testing results allow almost all cases of IDH-mutant gliomas to be diagnosed unambiguously as oligodendrogliomas or astrocytomas, with TERT promoter, CIC and FUBP1 variants adding further clarity [Historically, oligoastrocytoma has been defined as an infiltrating glioma composed of two distinct neoplastic cell types, with oligodendroglial and astrocytic features, respectively . Accordi clarity , 15, 18. clarity . Astrocy clarity . Here weWe present the case of a 29-year-old female with a left frontal glioma, which demonstrates two components that are morphologically, immunohistologically, molecularly and radiologically distinguishable as “oligodendroglial” and “astrocytic.” The patient initially presented with a new onset generalized seizure, preceded by 2 weeks of increasing headache, restlessness and intermittent fatigue.Initial magnetic resonance imaging (MRI) demonstrated a high left frontal mass with two radiologically distinct components Fig. a-d. A moTissue examination of the resection of the medial component demonstrated low-grade IDH-mutant astrocytoma  studies were performed as previously described  on the iAfter her second resection, the patient returned to work and was followed by close clinical and imaging observation, without radiation or chemotherapy. On follow-up imaging, no progression was noted over the course of 4 months after the second resection, but slow progression was seen at 6 and 8 months after the second resection . At that time, the patient noted fatigue, as well as cognitive and speech decline. MRI demonstrated increasing T2/FLAIR nonenhancing signal abnormality at the margins of resection in the superior frontal gyrus and extending inferiorly to the corona radiata. Given the time interval of the follow up, the extent of the change was more than expected for a low grade glioma and in the absence of radiation therapy. A third surgery 10 months after the second resection demonstrated infiltrating low-grade glioma with a prominent astrocytic component . Immunohistochemical stains were performed on multiple blocks, and showed a consistent astrocytoma pattern, despite the oligodendroglial features. The glioma was positive for the IDH1 p.R132H variant (b). Strong, nuclear staining for p53 was present in a subset of tumor nuclei (c), and ATRX was absent in a majority of tumor nuclei, with positive staining in endothelial cell nuclei and small scattered nuclei (d). The third resection demonstrated scattered tumor cells at the edge of the prior resection cavity (e), with IDH (f) and p53 (g) positivity. Many macrophages and microglia are highlighted by CD68 (h) Additional file 2.Additional file 3.


Intussusception is a form of intestinal obstruction in which a segment of the bowel prolapses into a more distal segment. It is an uncommon condition in children older than 2 years and causes intestinal obstruction. On the contrary of adult intussusception, childhood intussusception does not usually happen on a lead point of a malignant organic lesion.A 14-year-old male presented with complaints of heavy, bilious emesis and periumbilical colicky pain. Ultrasonography showed a dilated intestinal loop with absent bowel movement. CT scan revealed two masses in the abdomen.We performed an exploratory laparotomy that revealed invaginated intestines and showed a polyp near the area of interest. Necrotic segments and the polyp were removed and examined pathologically. Pathology showed adenocarcinoma in the polyp.After surgery, the general condition of the patient was normal and no complications occurred.Intussusception mainly occurs during infancy and early childhood. Mostly it is an idiopathic ileo-colic invagination. In our case, the patient had a jejuno-jejunal intussusception in his late childhood, and the lead point was an adenocarcinomatous polyp, which is rare in children. Amongst the many types of treatment, we chose surgical resection because of patient’s age. Intussusception is a form of intestinal obstruction in which a segment of the bowel prolapses into a more distal segment . It typiTreatment of intussusception includes enemas, surgical reduction, and surgical resection, however, cases in this age should only be treated with surgical resection .We present in this case a 14-year-old male who was diagnosed with jejuno-jejunal intussusception caused by a polyp that turned out to be an adenocarcinoma.A 14-year-old male was admitted to the hospital with complaints of colicky abdominal pain and severe emesis. The patient’s emesis had started 6 months earlier and was mild, but it has worsened during the last month and become more frequent with larger amounts.The child’s parents had given him over-the-counter antibiotics to treat a suspected gastroenteritis and they had no effect; on the contrary, the symptoms deteriorated bringing them to the hospital. The child had periumbilical colicky pain, nausea, severe emesis, anorexia, weight loss, and he was passing hard stools.The emesis started reflexive and non-bilious but soon before admission, it turned into bilious emesis. After admission, a Nasogastric Tube (NGT) was inserted and showed bilious emesis followed by fecal emesis, which suggested an intestinal obstruction. The patient did not have any relevant past medical history or drug history or any similar disease in the family.Physical examination showed a tender, rigid abdomen and no signs of fever. Rectal examination showed a fecal impaction. We evaluated vital signs upon admission: blood pressure: 100/70 mmHg, Pulse: 96 beats/minute.+: 132 mEq/L) (K+: 3 mEq/L) (Glucose: 96 mg/dl) (Creatinine: 0.63 mg/dl) (WBC: 10100 cell/ul) (Hemoglobin: 11.2 g/dl).Lab tests were:  [The histological examination of the polyp that caused the intussusception has revealed an adenocarcinoma. Adenocarcinoma of the bowels is often associated with a number of genetic conditions including: Peutz Jeghers syndrome, familial adenomatous polyposis and Lynch syndrome . The incThe intussusception that occurs in the absence of a lead point is classified as primary or idiopathic, whereas in the secondary, a lead point is identified , 9. In oOnly a few case reports reviewed an intestinal adenocarcinoma diagnosed in children –those cases were caused by specific cancer predisposing syndromes, e.g. Peutz Jeghers syndrome. A study conducted in 1984 showed a 12-year-old girl with primary small bowel adenocarcinoma but there was no polyp and it did not cause an intussusception of the small bowel . AnotherRegarding prognosis, the univariate predictors for prognosis are: age, severe intestinal symptoms at first diagnosis, T4 of tumor stage, tumor size, relatively late clinical stage, peritoneal metastasis and no chemotherapy. The multivariant predictors are age of more than 60 years old, intestinal obstruction or perforation at first diagnosis, relatively late clinical stage, and no chemotherapy .Early diagnosis of intussusception in adolescent patients is challenging because most cases present with nonspecific symptoms and have a chronic or subacute course .In our case, we decided to perform a surgery-only treatment without adjuvant therapy, because previous studies on small bowel adenocarcinomas showed that adjuvant therapy did not significantly improve overall survival of patients , especiaThis decision was taken after discussing the case in a tumor board, where it was recommended that a surgical resection of the adenocarcinoma along with its margins is enough in this case.In addition, we have completed an oncologic follow-up to assess prognosis of the resected adenocarcinoma and determine whether an adjuvant management is needed. This follow-up, however, was not long enough as the patient did not come back to the hospital due to the hindrances imposed by the local crisis.The exact cause of developing a gastro-intestinal tract adenocarcinoma in early adolescence is still vague. Studies offer insufficient information about the etiology or risk factors for such cases.In conclusion, our case is distinct because our 14 year-old patient developed an intussusception, which usually arises in infants, had no signs and no familial record of any cancer predisposing syndrome and exhibited a rare type of intestinal carcinoma. Thus, surgeons treating patients with acute abdomen should always keep in mind that the presenting symptoms of intussusception are non-specific and the underlying causes could be life threatening especially in older patients.


A rare case of synchronous ipsilateral pleomorphic adenomas (PA) of the left parotid and submandibular glands is reported. Simultaneous multiple PA in major salivary glands are a very rare entity, and merely few cases of ipsilateral synchronous PA involving parotid and submandibular glands are reported in the literature. The case of a 40-year-old female with a six-year history of asymptomatic growing lesion in both left parotid and left submandibular regions is presented. Left superficial parotidectomy and left submandibular gland excision at the same surgery have been performed. The aim of this article is to highlight the importance of an accurate head and neck presurgery examination both clinically and radiologically, keeping in mind the possibility of multiple tumor location. Among head and neck neoplasms, salivary gland tumors are around 2.0–6.5% .Pleomorphic adenoma, a benign mixed tumor with both epithelial and connective components, is the most common benign neoplasm occurring in the salivary glands –4.Mostly located in the parotid gland (about 80%), it may originate from the submandibular gland and seldom from sublingual and minor salivary glands , 6.A single nodular expansive lesion located in one of these glands is the typical presentation, while in 3.4% of the cases, multiple masses are found. While Warthin's tumor is the most common histotype found in multiple salivary gland neoplasm, only few cases of multiple pleomorphic adenoma (MPA) are reported in the literature –13.Bilateral parotid location is the most common presentation of MPA. Synchronous unilateral pleomorphic adenomas involving both parotid and submandibular glands are extremely rare, and merely ten cases have been reported in the literature till date –25.Herein, a case of synchronous multiple pleomorphic adenoma affecting both the parotid and ipsilateral submandibular glands is presented.Considering this uncommon possibility, our findings confirm the importance of meticulous presurgery examination when a single salivary gland tumor is detected.In March 2019, a 40-year-old female was admitted to our Maxillo-Facial Surgery Department, at “La Sapienza” University, Sant'Andrea Hospital of Rome, Italy, with two voluminous masses in the left preauricular and left submandibular regions. Her past medical history was well assessed.She first noticed these lesions about 6 years ago, when they were the size of a bean. The gradual growth was referred by the patient and documented by annual ultrasonography exams. Three years ago, she performed an FNAC that was suggestive for pleomorphic adenoma. Finally, she presented to our attention.No history of pain, fever, trauma, difficulty in mouth opening, or facial nerve weakness was referred. No risk factor like smoking or previous radiation exposition was found.Physical examination revealed two solid masses, one in the left preauricular parotid region and the second one in the left submandibular region, both well-circumscribed, hard-elastic, not fixed to the adjacent anatomic structures. No enlarged cervical lymph nodes were detected. There was no evidence of facial and trigeminal nerve dysfunction, and the skin overlying masses was normal.A contrast-enhanced MRI of the head and neck was performed and showed a well-defined slightly lobulated mass (20 × 25 mm) with inhomogeneous peripheral enhancement in the left parotid gland and a second mass with well-defined nodular aspect (30 × 26 mm) and central inhomogeneous enhancement in the left submandibular gland .In May 2019, right-sided superficial parotidectomy and right submandibular gland excision at the same surgery were performed.A preauricular and pretragal incision with cervical extension was executed to obtain a complete exposure of both parotid and submandibular glands.Moderate weakness of mandibular branches of the left facial nerve was early evaluated after surgery. Complications were not observed, and the postsurgical period was regular.A 3-month follow-up revealed complete recovery of facial nerve weakness .Histopathological evaluation confirmed the benign pleomorphic adenoma diagnosis of both lesions .Multiple salivary gland tumors are a rare entity observed only in 3.4% of cases. Warthin's tumor is the most common histotype while uncommon cases of multiple pleomorphic adenoma (MPA) are reported in the literature –13.MPA usually affect both parotid glands, and a unilateral localization involving both parotid and submandibular glands is a very unusual event; merely ten cases have been reported in the literature till date –24.A large amount of theories were discussed about the origin of these multiple tumors both considering these lesions as two unrelated primary sites of tumor and multiple foci of a low-grade malignant neoplasm , 26–28.According to the last theory, multiple pleomorphic adenomas are considered as lesions with low-grade malignant potential with poorly understood pathogenesis, also known as metastatic pleomorphic adenoma .In 1953, Foote and Frazell  first deAccording to Alshgroud et al. when considering MPA, it is important to evaluate the age of the patient, the location of the presumed metastatic lesion, the number of recurrences, the period between the primary and metastatic lesions, the possibility of iatrogenic spread, the histopathology of both lesions, the possibility of the presence of other metastatic lesions, and any chromosomal or molecular similarities between the two lesions .Considering that metastatic lesion is most located nearby the previously operated surgical site, Singh et al. hypothesized that this new lesion could be a result of tumor spreading through the lymphovascular system at the time of primary excision, even if the possibility of metastasis from one gland to the other cannot be excluded yet .Klijanienko et al. suggested that metastasizing pleomorphic adenomas may represent unrecognized malignancy with 20% death rate associated .Regarding another risk factor for multiple pleomorphic adenomas, radiation was described by Nagler and Laufer .Although our patient was not exposed to radiations nor presented history of surgery or trauma or any other risk factor, she has developed multiple pleomorphic adenoma.For all salivary gland neoplasms, single or multiple, unilateral or bilateral, the treatment of choice is complete excision of the lesion with adequate resection margins. In the case of parotid tumors, a superficial parotidectomy or total parotidectomy depending on the location and sizes of the tumor should be performed. However, in submandibular gland tumors, the removal of the whole gland is suggested to ensure complete disease removal , 33.Superficial parotidectomy is no risk free, and transient or permanent facial nerve paralysis, Frey's syndrome, salivary fistula or subcutaneous effusion, infection, xerostomia, scar deformity, great auricular analgesia, hematoma, and seroma may occur , 35.Furthermore, submandibular gland excision's complications include transient or permanent palsy of the mandibular branch of the facial nerve, transient or permanent palsy of the lingual nerve, hematoma, wound infection, and salivary fistula .Bearing in mind that the occurrence of these complications is mostly related to the postoperative period and to the surgery procedure, performing simultaneously submandibular excision and superficial parotidectomy reduces, but not eliminates, the net risk of surgical site or wound infection and hematoma.The preauricular and pretragal incision with cervical extension permits to obtain a complete exposure of both parotid and submandibular glands giving the surgeon great operative field visibility with a good aesthetic outcome.Moreover, in case of a single surgery, the intrinsic risks of general anaesthesia are reduced compared to the risk of two separate surgeries.On the other hand, single surgery is more invasive and requires adequate surgical experience and a careful postoperative follow-up.Despite that, considering the numerous advantages of the technique, the authors strongly recommended simultaneous ipsilateral parotidectomy and submandibular gland surgery for synchronous ipsilateral parotid and submandibular gland tumors.Our case and the literature review highlighted the importance for an accurate head and neck presurgery examination, including clinical patient history, risk factors, tumor location, its histological typing, and the evaluation of other salivary glands with radiological exams keeping in mind the possibility of multiple tumor location.In these cases, postsurgery follow-up is becoming of particular importance for early possible multiple foci and recurrence detection.


Congenital hypoplasia of depressor angularis oris muscle (CHDAOM) is an uncommon cause of asymmetric crying facies in neonates. Although its etiology is mostly unknown, it has been increasingly recognized as a marker for the presence of other less easily identifiable congenital abnormalities associated with genetic syndromes such as DiGeorge and Cayler syndrome. We report a unique case of a male neonate that highlights the necessity of judicious and accurate clinical documentation with the presence of CHDAOM to avoid unnecessary forms of subsequent work-up. Asymmetric crying facies (ACF) is characterized by unilateral facial weakness of the lower lip which becomes prominent especially when the infant is crying. Having been reported as often as one in 160 live births, ACF is not particularly rare ,3. ThereA male neonate was born via low transverse Cesarean section to a 27-year old gravida 2, para 2 mother at 39 weeks and zero-day gestation. Apgar scores were 8 and 9. Past medical history and family history were noncontributory. The prenatal and perinatal periods were uneventful, and the nursing staff expressed that no instrumentation was used for delivery that may have resulted in a known birth trauma. Deviation of the lower lip to the left side while crying, suggesting right-sided muscle weakness, was noted at the time of delivery Video . This, h The patient was diagnosed with right-sided ACF due to CHDAOM along with an idiopathic cephalohematoma. At the time of discharge, the parents elected to receive care at an affiliated primary care office in the locality. In communicating with the providers at the affiliated health facility, the report was that the baby had remained clinically stable. The facial asymmetry showed progressive but slow improvement, and as previously noted it did not seem to affect the patient’s ability to feed normally. He had regained birth weight by the two-week well child visit.ACF is a broad term describing a unilateral lower lip asymmetry that becomes evident in a crying neonate but is symmetric while at rest. Nerve compression and abnormal muscle development have been suggested as possible causes . CompresCHDAOM can present as an isolated finding but also can occur with other congenital malformations in up to 45%-70% of cases -5. TheseIn this index case, we considered the need for imaging to rule out a possible associated congenital anomaly given the presence of the head swelling, which had been suspected to be a cephalohematoma and did not really require an imaging study, such as an MRI to confirm. Our case underlines the need for accurate clinical documentation in helping to delineate an otherwise relatively rare clinical condition without the involvement of unnecessary expensive imaging or other forms of work-up.


Large paraganglioma of the Zuckerkandl organ (POZ) is extremely rare. The patient can occasionally be paucisymptomatic, further obscuring the diagnosis and carrying high mortality. Recommended treatment for large paraganglioma (PGL) is open surgical removal. We report a case of successful laparoscopic resection of a large POZ with normal blood pressure in a 45-year-old man.A 45-year-old man was hospitalized because of hyperglycemia. Computed tomography of the abdomen and the serum and urinary catecholamine levels confirmed the diagnosis of large POZ. But his blood pressure was normal and he underwent laparoscopic tumor excision successfully. During 6 months follow-up after laparoscopy, serum and urinary catecholamines were normal but glycaemia remained high level. DNA analysis of the succinate dehydrogenase complex subunits B (SDHB) and SDHD revealed no mutation.POZ is an unusual mass and preoperative diagnosis can be difficult in clinically silent cases. PGL cannot be excluded in patients with normal blood pressure. Even a large POZ can be excised laparoscopically by following proper techniques. PGLs are catecholamine-producing tumors that may occur anywhere along the sympathetic paraganglionic chain . The treA 45-year-old man with a half-year history of hyperglycemia presented to endocrinology. The patient denied attacks of headache, hypertension, palpitation and sweating. He was kept for observation with 24-h electrocardiography (ECG) and blood pressure monitoring which was normal. His glycaemia returned to normal level under the action of insulin. Haematological and biochemical investigations were normal except for elevated serum and urinary catecholamines Table . Both thWe made full consideration and preparation for possible conversion to open surgery before deciding to adopt laparoscopic surgery. If there were acute bleeding, small operation space, malignant tumor invasion or other parts of the injury that have to be converted to open surgery, we will use a longitudinal incision under the right costal margin for open surgery. In addition, we also communicated with vascular surgeons that if the aorta or the inferior vena cava were damaged, open resection and reconstruction of these vessels might be warranted.The patient was placed in 70° left lateral decubitus position, and a 10-mm trocar was inserted above the umbilicus for telescope using. Another 10-mm, 10-mm and 5-mm trocar were placed under the right costal margin, right anterior axillary line and subxiphoid, respectively Fig. . A steepPGLs are rare catecholamine-secreting neuroendocrine tumors that arise from the extra-adrenal paraganglia. Most PGLs occur in the subdiaphragmatic region, most commonly within the organ of Zuckerkandl . The cliA giant PGL/pheochromocytoma usually present with paucity of clinical signs and symptoms , 15. ThePreviously, it was considered that there were no guidelines to ensure adequate preoperative preparation in these clinically silent tumors . The preMost PGLs appear to be sporadic; however, about 30–35% of tumors are associated with hereditary syndromes, mainly multiple endocrine neoplasia type 2 (MEN-2), von Hippel Lindau (VHL) disease, and neurofibromatosis type 1(NF1) . 70% of In conclusion, POZ is an unusual mass and preoperative diagnosis can be difficult in clinically silent cases. PGL cannot be excluded in patients with normal blood pressure. Even a large POZ can be excised laparoscopically by following proper techniques.


Differential diagnosis in non-traumatic acute abdomen is broad and unrelated diseases may simulate each other from a clinical perspective. Despite the fact that they are not as common, acute abdominal pain due to diseases related to visceral vessels may be life-threating if not detected and treated promptly. Thrombosis, dissection, and aneurysm in the abdominal visceral arteries or thrombosis in visceral veins may cause acute abdominal pain. Imaging with appropriate protocoling plays a fundamental role in both early diagnosis and determination of the treatment approach in these cases where early treatment can be life-saving. Computed tomography (CT) appears to be the most effective modality for the diagnosis as it provides high detail images in a very short time. Patient cooperation is also a less concern as compared to magnetic resonance imaging (MRI). As the imaging findings may sometimes be really subtle, diagnosis may be difficult especially to inexperienced imagers. Correct protocoling is also very critical to detect arterial abnormalities as visceral arterial abnormalities may not be detectable in portal phase only abdominal CT scans. In this article, we aimed to increase awareness among imaging specialists to these not very common causes of acute abdomen. Abdominal visceral vascular disorders may present with acute abdominal pain and may have life-threatening consequences. Therefore, prompt evaluation of these patients is of fundamental importance.Appropriate protocoling of the imaging studies and familiarity to the radiologic findings of several different visceral vascular abnormalities may facilitate the diagnosis and may allow better treatment planning.Imaging findings may be subtle in these patients and early diagnosis may be of crucial importance in preventing conditions of high morbidity and mortality.Acute abdominal pain (AAP) is a common complaint among patients presenting to the emergency department (ED). AAP is approximately 5% of all ED visits in the USA in 2017 . AM. AM56]. Ovarian vein thrombosis (OVT) is a rare clinical condition which typically associates with pregnancy, malignancy, inflammatory bowel disease, and pelvic inflammatory disease 58]. The reported rate is around 0.05% to 0.16% and is most commonly seen in early postpartum period. Right gonadal vein is more commonly affected (around 90%) than its left counterpart and incompetent valves, longer length, and dextrorotation of the gravid uterus may be counted among the contributors to this condition. Ovarian vein diameters increase up to threefold during pregnancy which may lead to stasis and subsequent venous thrombosis [. The repThe most commonly encountered clinical presentation is the triad of pelvic pain, fever, and right-sided abdominal mass. Tachypnea, flank pain, ileus, nausea, and vomiting may also be seen in affected patients. Blood cultures are rarely positive and symptoms most commonly occur in the first 4 weeks of the postpartum period .Imaging diagnosis may be difficult with US as ovarian veins lie deep in the retroperitoneum shielded by intraperitoneal organs. CT is the most commonly used modality in suspected patients and diagnosis may be made promptly with CT. Reformatted images are extremely helpful. The thrombosed ovarian vein appears as an enlarged vessel with an endoluminal filling defect Fig. . AnticoaAcute mesenteric ischemia (AMI) may be a devastating disorder with a grave prognosis. Superior mesenteric artery (SMA) embolism and thrombosis are the most common causes of AMI. However, severe hypotension or metabolic shock may also cause nonocclusive mesenteric ischemia (NOMI) in patients with patent SMA due to severe reduction and redistribution of the mesenteric arterial flow .SMA is the feeding artery of the midgut and is the second major branch of the abdominal aorta. This vessel is particularly vulnerable to embolism from distant sources due to the acute take-off of the vessel origin from the abdominal aorta. Occlusive thrombotic disease of the SMA may have grave clinical consequences. The clinical symptoms are mostly related to abdominal pain . ArteriaSMA embolus generally originates from the left atrium as a result of atrial fibrillation in elderly patients. Thrombi and large emboli may occlude the proximal part of SMA and ostia of its major branches; however, distal branches may also be affected with smaller emboli. The majority of these emboli typically lodge within the proximal 3–10 cm of the SMA; therefore, proximal jejunum and colon may be spared . The preMultidetector CT of the abdomen with IV contrast injection is the first-line modality. Both arterial and venous phase images should be acquired to evaluate both arterial and venous mesenteric vessels. Isotropic reformatted images and maximum intensity projections images in several different planes may be extremely helpful for evaluating the extension of the vessel involvement .Emboli or thrombi typically appear as low-attenuating filling defects in the mesenteric vessels. The associated features of intestinal ischemia should also be searched for Fig. . PersistNOMI is usually a consequence of mesenteric vasospasm and contraction . It typiSMA dissections can be an isolated event or combined with aortic dissection. Combined SMA dissection is more common and is secondary to an aortic flap extending into the SMA lumen. Spontaneous SMA dissection is a rare clinical phenomenon that occurs without associating aortic flap . Even thSMA aneurysm is the third most common type of non-traumatic visceral artery aneurysms and accounts for 5.5% of all visceral artery aneurysms. They are most commonly detected within the first 5 cm of SMA and may be saccular or fusiform in shape. Infection, dissection, atherosclerosis, and pancreatitis are among the common causes , 67. UnlCT angiography is the preferred imaging modality for detecting SMA aneurysms. The aneurysm morphology is variable and may appear as either saccular or fusiform in shape Fig. . AssociaDue to the high incidence of rupture and complications, treatment is indicated for most SMA aneurysms regardless of their size . TreatmeSMA syndrome is caused by compression of the third part of the duodenum between SMA and the abdominal aorta. The duodenum is surrounded by adipose tissue, which serves as a cushion against external compression  . In patCT is the most commonly used modality for diagnosis. Aortomesenteric angle measurement is crucial for diagnosis and an angle less than 22° and the aortomesenteric distance of less than 8 mm  Fig. . The norIsolated spontaneous celiac artery dissection, without associating aortic dissection, is a very rare clinical event . Due to CT and MRI may both be used for diagnosis but due to its versatility; contrast-enhanced CT appears to be more pertinent for diagnosis. On CT, dissection flap may be directly seen; however, intramural hematoma with/without associating penetrating ulcer may also be detected . DissectCeliac artery thrombosis is an unusual cause of acute abdomen. Early diagnosis is crucial as the consequences may cause high morbidity and mortality when the diagnosis and treatment are delayed .It is frequently associated with other cardiovascular events. The most common etiology is atherosclerosis. Further, 20–30% of cases may have symptoms of chronic mesenteric ischemia . Post-coDunbar syndrome (the median arcuate ligament syndrome) is typically caused by compression of the celiac artery ostium by a low insertion of the median arcuate ligament. Abdominal pain may be observed in certain patients related to this phenomenon. CTA may outline the characteristic imaging feature of this syndrome. Post-stenotic dilatation and collateral vessels from SMA may be observed in patients with severe stenosis .Splenic artery aneurysm (SAA) is a rare clinical condition with an estimated prevalence of 0.2–10.4% . HoweverCT is the most commonly used imaging modality for diagnosis. The SAAs typically reside in the distal third portion of the splenic artery (74–87%), followed by the middle third segment (22%). It is observed as an extra filling pouch along the course of the artery and may have peripheral wall calcifications, indicative of atherosclerotic changes Fig. . SurgeryGastroduodenal artery pseudoaneurysms (GDAP) are most commonly seen after acute pancreatitis, or less commonly, after gastric or pancreatic surgeries . Early dCT is the imaging modality of choice and allows detection in the majority of the cases Fig. . EndovasThe diseases related to visceral arteries are not among the common causes of the acute abdomen but delay in diagnosis and treatment may carry a very high risk of morbidity and mortality. High index of clinical suspicion and meticulous evaluation of the imaging studies, as the findings may be extremely subtle, are two most important parameters for diagnosis and early intervention.CTA should be the first-line modality to be utilized in these patients as it can provide an accurate diagnosis in a prompt manner. Appropriate protocoling of CTA is critical and a proper study should include non-contrast images followed by arterial and venous phases. Delayed phase images may also be implemented in clinically relevant situations under radiologists’ discretion. With CTA, both vascular structures and secondary effects of visceral vessel abnormalities can be simultaneously evaluated. Solid-organ infarcts, bowel wall abnormalities, the presence and extent of intraabdominal free fluid, and hematomas may also be precisely assessed with CT. The role of CT may be even more accentuated in patients who are hemodynamically unstable and need urgent treatment.In addition to initial diagnosis, CT has also a significant potential to guide the endovascular, medical, or surgical treatment approaches as well as in follow-up of these patients.


Case Presentation. A fifty-one-year-old obese female presented with a progressive visual loss, abducens nerve palsy, and headache for three months. Further investigations revealed a right frontal tumor and ventriculomegaly on magnetic resonance imaging. Her symptoms improved remarkably after total surgical excision of the tumor with a ventriculoperitoneal (VP) shunt.  Idiopathic intracranial hypertension (IIH) and normal pressure hydrocephalus (NPH) are disorders of the cerebrospinal fluid (CSF) flow dynamics. Pleomorphic xanthoastrocytoma (PXA) is a rare low-grade astrocytoma  representing <1% of astrocytomas. Combination of IIH and NPH with PXA is unheard of, with few published cases discussing the association of CNS tumors with either IIH or NPH, but never combined. We present a case of a 51-year-old woman with such a rare combination.  The pathophysiology behind NPH and IIH is still not fully understood, yet their management is mostly dependent on CSF diversion. The concomitant development of two different CSF dynamic diseases with a PXA has not been reported in the literature. We hypothesize that PXA may have sparked an abnormal CSF circulation pattern and ventriculomegaly. IIH, widely known as pseudotumor cerebri, and NPH are disorders attributed to the CSF circulation dynamic. Although they have different pathophysiologies and opposite diagnostic features, they are primarily managed by CSF diversion . NPH freA fifty-one-year-old obese lady with a body mass index of 45.3, known to have hypertension and dyslipidemia, was referred to our institute as a case of a right frontal mass lesion associated with hydrocephalus . Her symPhysical examination showed a fully awake patient with a nonreactive right pupil of 5 millimeters and a sluggish left pupil of 6 millimeters in size; ophthalmoscope examination showed bilateral pale edematous optic disk, right oculomotor cranial nerve palsy, left abducens cranial nerve palsy, and a decreased sensation of the entire right side of the face to pinprick. Upper and lower limb sensory and motor examinations were normal. The patient was investigated with an MRI, magnetic resonance venography, and magnetic resonance perfusion that showed patent venous sinuses . The MRI2O; initially, the drained CSF was xanthochromic then started to clear gradually. The physical exam postoperatively shows normal movement of all her limbs with reactive bilateral pupils. Histopathological assessment was evident for large areas of necrosis without a nuclear pseudopalisading or significant mitotic activity, which is consistent with the features of grade II WHO PXA.The patient underwent a right frontal craniotomy for tumor resection and insertion of an external ventricular drain as her intracranial pressure (ICP) was very high intraoperatively ranging between 28 and 30 cmHSerial postoperative examinations showed remarkable improvement in her presenting symptoms, including visual acuity, gait, and urinary incontinence. Postoperative MRI showed complete resection of the tumor . The patTo our knowledge, no similar case of a simultaneous IIH, NPH, and PXA was mentioned in the literature. However, there have been a few cases that reported associations of NPH or IIH with a space-occupying lesion . There wThe second case was a sixty-eight-year-old male patient who presented with involuntary left arm movement, followed by progressive gait impairment and urinary incontinence. Neuroimaging studies revealed a lesion in the right frontotemporal region. Partial resection was done, and the histopathological diagnosis demonstrated a glioblastoma (WHO grade IV). However, due to the tumor progression, the patient died after three months . Another2O. The patient was started on acetazolamide and dexamethasone; however, she did not show any improvement. MRI was conducted one week after admission and revealed a discrete signal hyperintensity of the gyri surrounding the left central sulcus with no mass effect. Five weeks later, a VP shunt was placed due to visual deterioration, and CSF examination revealed glial fibrillary acidic protein-positive cells with no anaplasia. Brain biopsy showed the characteristic features of a PXA [Another case report has described a 27-year-old woman who presented with a three-day history of headache and progressive visual loss in both eyes. Initially, she received a diagnosis of IIH as the computed tomography scan revealed no abnormal findings, and a lumbar puncture yielded a CSF pressure of 430 mm of HThe case we described combines three different and unrelated disease entities, with an independent pathophysiological mechanism. As in our patient, the presentation of the case by Delgado-Alvarado et al.  generateWe report the first case of a simultaneous IIH, NPH, and PXA. No clear association can be described between them; however, it may be related to PXA-induced ventriculomegaly with NPH clinical presentation and a defect of CSF absorption, leading to IIH clinical presentation.


Dear Editor,Congenital Melanocytic Nevus (CMN) is characterized by pigmented lesions present at birth or in the first weeks of life. The Giant Congenital Melanocytic Nevus (GCMN) form presents a minimum extension of 20 cm in adult life and is rare . In addition to being an unsightly condition, giant CMN presents additional risks of extracutaneous morbidities such as neurological complications. A complicating factor is the presence of melanocytic cells in the Central Nervous System (CNS), a comorbidity called Neurocutaneous Melanosis (NCM).We report a case of female patient, accompanied since the age of 2 years with GCMN in garment. In clinical follow-up, no neurological symptoms or changes in psychomotor development were detected. A brain Magnetic Resonance Imaging (MRI) confirmed the presence of T1-Weighted (W) images in the left parietal region, corresponding to neurocutaneous melanosis. The diagnosis was made upon typical imaging and skin findings.Dermatological examination revealed a brownish-black plaque, with evident hypertrichosis, extending from the cervical region to the knees, garment-like, with multiple satellite lesions on the face, upper and lower limbs . The patBrain MRI scan demonstrated the presence of a single solid expansive lesion measuring 5 cm × 3.5 cm in the left fronto-parietal region, associated with an intense vasogenic edema, promoting midline deviation . HistopaThe immunohistochemical examination showed strong reactivity to the panel of antibodies S100, HBM45 and Melan A. Additional imaging studies showed no metastasis. The final diagnosis was primary melanoma of leptomeningeal. The patient died from intracranial hemorrhage followed by cardiorespiratory arrest four months after diagnosis.Primary CNS melanoma is a rare disease. It represents 1% of melanomas and approximately 0.05% of primary malignancies of cranial tumors. These can be divided into nodular intraparenchymal and diffuse leptomeningeal patterns.2The risk of estimated lifetime MM-all sites for individuals with CMN is around 5%, with increased risk to 12% in patients with neurocutaneous melanosis. This is characterized by the migration and erroneous proliferation of melanocytic cells in the CNS from neural crest melanoblasts.3NCM involves several additional comorbidities which include hydrocephalus, convulsions, cranial nerve palsy, neuropsychiatric disorders and the risk of malignant degeneration of the cells. Mortality rate is close to 100% for CNS MM cases and 70% of patients with neurocutaneous melanosis will die before 10 years of age.3This aggressive entity found within the context of CMN is due to a different biological behavior with the presence of somatic mutations in 81% of cases in the NRAS gene of the melanocytes, in detriment of the mutations BRAF, demonstrating that they are genetically different from nevi developed after birth and an important risk factor for primary CNS and cutaneous melanoma.NRAS-mutant tumors tend to behave more aggressively particularly in early stages of the disease. In view of this differential genetic behavior, target therapies have been investigated for CNS melanoma in patients with CMN and the proven mutation of the protoncogene NRAS. Initial studies have demonstrated results of MEK inhibitors, Trametinib, in symptom control and improved quality of life, an important step in the discovery of treatment for this condition.5Evidence indicates a higher incidence of this neoplasm in patients presenting multiple satellite lesions, such as the pattern in garment-like, and/or paravertebral or axial location.3CNS melanoma currently emerges as the major limiting prognostic factor in children with CMN. In this scenario, cutaneous melanoma plays a less decisive role, influencing the decision toward prophylactic surgical excision. Brain MRI is important in this scenario, which should preferably be performed in the first year of life, since the incidence of CNS and cutaneous MM in the group with altered examination is 12%, as opposed to MM incidence of 1% in the group with normal CNS MRI at birth. The clinical follow-up of patients with altered MRI examinations should be annual.None declared.Adriana Kamilly Leitão Pitman Machado: Approval of the final version of the manuscript; conception and planning of the study; elaboration and writing of the manuscript; critical review of the literature; critical review of the manuscript.Débora Bacellar Cruz Nunes: Elaboration and writing of the manuscript.Francisca Regina Oliveira Carneiro: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Alena Margareth Darwich Mendes: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.None declared.


Ectopic pancreatic tissue is often incidentally encountered during abdominal surgery. We report a case of an incidental finding during a laparoscopic appendectomy, the approach to diagnosis and management of this.The work has been reported in line with the SCARE criteria.A 32 year-old woman was diagnosed with an intramural pre-pyloric mass during a laparoscopic appendectomy. The lesion was identified on a subsequent computed tomography as a homogenous mass on the greater curvature. Upper esophagho-gastro-duodenoscopy was normal. The intramural mass was confirmed by an endoscopic sonography and the fine needle biopsy showed aspecific inflammatory cells. A laparoscopic wedge resection was realized. Histopathologic examination confirmed the diagnosis of an ectopic pancreatic tissue.The management of ectopic pancreas poses a medical challenge. The diagnostic quiver consists of radiologic exams and endoscopy, in combination with a direct biopsy of the lesion.Despite the plethora of diagnostic modalities available, a definitive diagnosis for heterotopic pancreas often remains elusive, requiring more invasive diagnostic means. Although ample information is available in literature, there are currently no evidence-based guidelines regarding diagnosis and management of heterotopic pancreas. AlthougStructurally the ectopic pancreatic tissue resembles the orthotopic pancreas in gross and microscopic anatomy and appears as a firm, intramural nodular mass ,6. A claMost lesions are unifocal 80%) and up to 80% are reported to be less than 3 cm in size 0% and up. LiteratIn this case report, we present the case of a woman with a gastric ectopic pancreatic tissue located incidentally during a laparoscopic appendectomy in our community hospital, showcasing the management process of this unexpected perioperative finding.2A 32 year-old woman with no significant medical history was admitted to our hospital presenting symptoms of lower abdominal quadrant pain. Physical examination revealed a soft abdomen with tenderness located at the right iliac fossa. Blood tests showed a mild leucocytosis and a moderate elevation of C-reactive protein. The diagnosis of appendicitis was confirmed with an ultrasound of the lower abdomen.A decision was made to proceed with an immediate laparoscopic appendectomy. During the exploration of the abdominal cavity, a pre-pyloric 3 cm mass was located along the greater curvature of the stomach. An appendectomy was performed and the decision to investigate the mass postoperatively was made.A subsequent computed tomography (CT) scan showed a homogenously enhancing mass of 12.7 × 12.7 mm , while aHistopathologic examination revealed a heterotopic pancreatic tissue within the gastric wall  with nor3To this day the management of ectopic pancreas poses a medical challenge. Although an abundance of information on the nature of the disease exists in the literature, as well as pertinent statistical data  the source of this knowledge is mainly case reports or retrospective studies of small patient pools, resulting into great statistical variance and inconsistency.Despite the evolution of diagnostic modalities, there is no golden standard for the diagnosis of this lesion nor a defined protocol to facilitate it exists. The diagnostic quiver consists of radiologic exams and endoscopy, in combination with a direct biopsy of the lesion.Radiologic tools that may be employed include upper GI series (UGI), ultrasound (US) and endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP). Radiologic findings in UGI, US and CT are well defined, while documentation of ectopic pancreatic tissue characteristics in MRI remain limited . DespiteGottschalk U et al. mention in their study that the use of EUS, although helpful in the diagnosis of subepithelial lesions, has limited efficacy in differentiating an ectopic pancreas from other lesions with similar appearance such as gastrointestinal stroll tumours (GISTs), submucosal neuroendocrine tumours, hamartomas and schwannomas. They also note a discordance in literature regarding the echographic characteristics of the ectopic pancreas . A potenEndoscopy of the upper GI tract is a tool with high sensitivity but low specificity for the diagnosis of ectopic pancreas. In EGD, the ectopic pancreatic rest appears as a submucosal mass with endoluminal growth pattern, while central umbilication can be noticed owning to the presence of a rudimentary ductal system. Due to the subepithelial nature of the lesion, superficial endoscopic biopsy is inadequate .Current data are unable to indicate a standardised and cost effective diagnostic procedure. Despite the modern imaging capabilities, the basis of the diagnosis of a gastric heterotopia remains the wedge resection of the lesion and histopathologic examination of the specimen . FurtherIn this case report we present a patient with a pre-pyloric mass incidentally found during a laparoscopic appendectomy. Despite of a series of exams that were performed, the lack of diagnosis posed the indication to return the patient to the operating theatre for a laparoscopic wedge resection of the lesion .4Heterotopic pancreas is a rare medical entity that is most commonly encountered as an incidental finding during a radiological test or perioperatively . ClinicaThere is no conflict of interests. None of the authors received no funding whatsoever except the regular salary from the hospital where they are employed.There was no funding nor any sponsors involved.The case report is exempt from ethical approval. No study was conducted; we report state-of-the art diagnostic work-up and treatment of a rare case for which the approval of the ethics committee was not needed.Written informed consent was not obtained from the patient but she gave us her consent by call. Because we were unable to receive the written consent from the patient, the head of our medical team has taken responsibility and confirms that an oral consent by phone call was obtained and that the paper has been sufficiently anonymised not to cause harm to the patient or their family. A copy of a signed document stating this is available for review by the Editor-in-Chief of this journal on request.All of the authors contributed to the data collection, analysis and interpretation and paper writing.Enrica Chiriatti (the First author) was responsible to : writing paper, study concept, data collection, data analysis.Paulina Kuczma: contributed to study design, communication with the Editor.Domenico Galasso: contributed to data collection.Evangelo Koliakos: contributed to study design.Edgardo Pezzetta: contributed to data analasys.Olivier Martinet: contributed to study concept.http://www.researchregistry.com: We do not register case reports that are not first-in-man or animal studies.The following information can be found on the website This is our case: it is a case report that is not a first-in-man study.Enrica Chiriatti, MD.Not commissioned, externally peer-reviewed.


Pulmonary artery intimal sarcoma (PAIS) is a rare tumor without clear syndromic presentation other than nonspecific symptoms of cough, dyspnea, and weight loss. This diagnosis is difficult due to challenging radiographic interpretations of multiple imaging modalities. We present a case of a 60-year-old male, who presented to his pulmonologist and underwent a CT chest with IV contrast that initially suggested primary lung carcinoma. CT angiogram showed significant vascular filling defects suspicious of an intravascular mass, rather than vascular invasion by lung lesions. The PET/CT scans further suggested a malignant process, but indistinguishable between an extravascular or intravascular etiology. Taking these results together, they suggested an intravascular malignancy, prompting a tissue biopsy, which ultimately led to a diagnosis of PAIS with metastases. Establishing a definitive diagnosis is essential as treatment and prognosis are different for sarcoma compared to carcinoma. There is no standard treatment to date, and management often includes a multidisciplinary approach involving surgery, radiation, chemotherapy, and targeted therapy. PAIS is a rare entity that cannot be diagnosed clinically and needs a multimodality approach for its diagnosis. Pulmonary artery intimal sarcoma (PAIS) is a rare tumor with poor prognosis that mimics conditions such as pulmonary artery pseudoaneurysm, extravascular tumor invasion, and thromboembolism. Often, there are diagnostic delays as symptoms are nonspecific and diagnostic investigations can be time consuming. PAIS is a rare entity, and our case demonstrates the extensive clinical and radiographical investigations necessary to establish this diagnosis.A 60-year-old African American male presented to his pulmonologist with a one-month history of persistent productive cough. He has been producing clear mucous, without any blood. His cough has been progressively worse throughout the past month. His cough was worse during the day and exacerbated by cold beverages and cold air. The patient denied other symptoms including shortness of breath, dyspnea on exertion, chest pain, hemoptysis, subjective fevers, chills, or night sweats. He denied typical symptoms for seasonal allergies and gastroesophageal reflux. The patient has a past medical history of sickle cell trait and atrial fibrillation. His past surgical history is notable for a laparoscopic sleeve gastrectomy resulting in a 150-pound weight loss five years ago. He has a family history of sickle cell disease, diabetes, and peripheral vascular disease, without any cancer. He also denied any weight loss, changes in appetite, dysphagia, or odynophagia. He denies any history of tobacco use or other recreational drugs but has a previous history of alcohol use. The patient has no occupational exposure to hazardous material and is a bus operator for the past several years. He denied any recent travel. He lives alone and is functional and independent at home without any need for supplemental oxygen. The patient had experienced a similar cough approximately one year prior with associated fevers, otalgia, and chest congestion. At that time, he was treated with a course of antibiotics resulting in complete resolution of his symptoms.His vital signs on presentation were within normal limits, and he was saturating well above 95% on room air. On physical examination, the patient appeared comfortable and was in no respiratory distress. He was well developed and well nourished. He was alert and oriented to person, place, time, and events. Cardiovascular exam was unremarkable. Pulmonary exam revealed normal respiratory effort and normal breath sounds, with no stridor, wheezes, rhonchi, or rales. The patient also did not exhibit any palpable cervical, supraclavicular, axillary, or inguinal lymphadenopathy. Laboratory testing, including complete blood count and basic metabolic panel, did not reveal any abnormalities. A chest X-ray , in compGiven the new radiographic findings, he was sent to the hospital for additional workup and was scheduled for CT-guided transthoracic needle biopsy. Tumor markers  at this time were all within the normal range. To further evaluate the patency of the pulmonary arteries, a chest CT angiogram was performed, which revealed a soft-tissue density mass in the right pulmonary artery with scattered bilateral lung parenchymal lesions concerning for metastatic pulmonary angiosarcoma with known osseous metastatic lesion involving T3 vertebrae. Fine-needle aspiration biopsy of the right lower lung mass was nondiagnostic with some atypical spindle cells in a background of necrosis. Given the concern for spinal cord compression, an MRI of the thoracic spine was performed which revealed enhancing lesions at the T3 posterior elements with epidural involvement and compression, as well as posterior T4 vertebral body. MRI of the cervical spine was without evidence of disease. Ultimately, the patient underwent a T3 laminectomy with a T2 and T4 partial laminectomy and a posterior thoracic spine fusion of T2-T5 with screws, rods, and allograft along with resection of a spinal epidural mass. Pathologic review of the biopsied epidural mass revealed an intimal sarcoma, with epithelioid and pleomorphic features, of high grade involving bone. There were 19 mitoses per 10 high-power field. Focal tumor necrosis was present (<50%). Immunohistochemistry noted rare scattered tumor cells positive for SMA, CMA (5/2), and AE (1/3), but was negative for S100, CK 7, HMB45, CK19, CK (5/6), EMA, CD31, and CD34. GMS and AFB special stains were negative for microorganisms. Additional immunostaining performed showed that the tumor cells were positive for SMA and desmin and negative for STAT-6 and SAT2B. BCL-1 stain revealed nuclear reactivity and few scattered tumor cells. INI-1 was retained. FISH was performed and demonstrated amplification of MDM2. Furthermore, CT abdomen/pelvis was negative for any metastatic disease. The patient was discharged home with pain control and instructions to follow-up outpatient with pulmonology, medical oncology, radiation oncology, and neurosurgery.The patient completed ten cycles of palliative radiation therapy to the T2-T5 region for a total dose of 3000 cGy. Following completion, he developed pleuritic chest pain and shortness of breath. He presented to a different hospital and underwent CT chest angiogram and was diagnosed with large right proximal pulmonary embolism and he was started on apixaban. He subsequently reported several episodes of blood-streaked sputum after initiation of anticoagulation. PET/CT was performed showcasing extensive hypermetabolic pulmonary nodules/masses, right much greater than left, and hypermetabolic poorly characterized right hilar and subcarinal lymphadenopathy along with concern for right pulmonary artery invasion. The patient was followed up with medical oncology and was recommended palliative chemotherapy with doxorubicin for his diagnosis of intimal sarcoma. His transthoracic echo demonstrated a normal ejection fracture of 60–65%. His treatment course was complicated by nausea, vomiting, oral mucositis, fatigue, weight loss, and insomnia. Additionally, he developed anemia and neutropenia requiring pegfilgrastim. He later developed fever and was treated with antibiotics for pneumonia. The patient completed six cycles of doxorubicin therapy. Posttreatment CT with contrast demonstrated reduction in size of pulmonary metastases and stable-appearing nonocclusive thrombus within the right main pulmonary artery . Repeat In this case, the patient presented with vague symptoms of cough, dyspnea, and weight loss. Initial imaging modalities, including chest X-ray and CT chest with contrast, were concerning for extravascular tumor compression from primary lung carcinoma. CT angiogram revealed a filling defect suspicious of an intravascular mass, rather than extravascular tumor invasion. PET/CT scan identified pulmonary artery involvement but was unable to differentiate between intravascular or extravascular etiologies. To arrive at the final diagnosis of PAIS with metastases, several different imaging modalities, in addition to a tissue biopsy, were employed.A multimodal approach, utilizing several imaging modalities to visualize the thorax and vasculatures via CT, PET/CT, and MRI, is the best way to rapidly diagnose PAIS ,2. The dTissue biopsy by endobronchial ultrasound-guided transbronchial needle aspiration followed by immunohistochemistry remains gold standard for diagnosis . In thisThere is no standard treatment to date, and management often includes a multidisciplinary approach involving surgery, radiation, chemotherapy, and targeted therapy. Surgery is considered first-line treatment in order to relieve pulmonary artery obstruction and associated pulmonary hypertension and to palliate symptoms . SurgicaPAIS is a rare entity often resembling lung carcinoma or pulmonary thromboembolism as a result of nonspecific symptomatology and analogous imaging findings, thereby delaying diagnosis and treatment. There is no standard of treatment for PAIS and its treatment often involves a multidisciplinary approach, with anthracyclines as the main systemic agent.


Congenital pelvic malformations are rare and represent a difficult therapeutic challenge. Scrotal arteriovenous malformations are quite unusual, with only a few such cases reported in the literature. Only one case of scrotal malformation? due to an arteriovenous fistula resulting in azoospermia has been described.The two-phase strategy adopted in that case permitted complete treatment of a large-sized malformation that was served by 4 main blood confluences.Angio-CT performed using reconstructions with MIP and SSD algorithms provided more detailed data about the extension of the afferents and efferents of the arteriovenous malformation, thus enabling us to plan the endovascular treatment of the lesion.A multidisciplinary approach is mandatory to achieve good results in these cases. Congeni2At the Vascular Surgery Department of our Institution, we examined a male patient (42 years old) who presented with a scrotal tumefaction. This tumefaction was approximately 15 × 17 cm in size and had been progressively developing after surgery for the removal of a left-side testicular angioma. Secondary sterility had occurred, as suggested by a spermiogram that revealed azoospermia . Ultrasonographic test results performed during hospitalization revealed a diagnosis of scrotal arteriovenous malformation and a small fluid slope in the left tunica vaginalis; the testicles appeared to be regular in shape and had an echographic pattern. The patient underwent an angio-computed tomography (CT) of spiral multislides of the abdominal aorta and the lower limbs. The exam results indicated the presence of a raw agglomerate of enlarged blood vessels located in the left-1 side scrotal portion that was causing a contralateral dislocation of the right testicle . The mas3Testicular arteriovenous malformations are very rare lesions that represent less than 1% of vascular neoformations; they can be congenital, traumatic or iatrogenous . Because4Scrotal malformations are quite rare, and they can involve problems related to the therapeutic strategy chosen. The multidisciplinary approach used in this case involved a less invasive treatment protocol and subsequently less risky surgery. This strategy allowed the complete exclusion of the malformation and the retention of erectile capacity but did not improve organ function, a goal that remained unmet. To obtain a conclusive evaluation, an additional period of time is required to monitor the regression of the tumefaction in the long term as well as the aesthetic results and eventual benefits regarding fertility.No funding was declared and the acknowledgement are reported at the end of the text. Authors declare that the sponsor have no role in the study, in the collection or analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.The patient give the consensus to the procedure. Ethical approval is exempt for case reports by our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Study concept or desig: AAM, GC, RG and AI.Data collection: AAM, GC, RG and AI.Data analysis or interpretation: AAM, GC, RG and AI.Writing the paper: AAM, GC, RG and AI.This publication is free from Registration of Research Studies, because is not used a new technology.Prof. Arnaldo Ippoliti, Prof. Andrea Ascoli Marchetti.Not commissioned, externally peer-reviewed.The authors declare to have no conflicts of interest or any financial and personal relationship with other people or organisations that could inappropriately influence (bias) our work.


Choristoma is a non-neoplastic growth of normal tissues in non-indigenous site of origin. Osseous Choristoma is an ectopic bone formation which is a rare entity with 72 cases has been reported in the tongue, 15 cases in the buccal mucosa, 1 case in the lower lip. A 43 year old male patient experienced a mild, intermittent, dull aching type in the upper lip. An excisional biopsy was done by placing a single incision under local anesthesia. To our knowledge case is first to be reported in the upper lip as a result of reactive pathogenesis.As per literature, surgical excision is the treatment of choice for osseous Choristoma. Malignant transformation has not been reported yet. It can be formed from various tissues like bone, cartilage, muscle, glial cells, salivary glands, sebaceous glands. They are named after the tissue of origin . The tongue is the most predominant sites affected intraorally followed by buccal mucosa, palate  Developmental theory. b) Reactive or Post- traumatic theory.Developmental theory states that the entrapment of undifferentiated mesenchymal cells proliferates into a sessile or a pedunculated mass. According to Adhikari et al, the derivatives of brachial arches are trapped to proliferate within the normal cells in alien site . The ent. His Past medical history was non-contributory and in the past dental history the patient revealed the history of trauma from road traffic accident 15 years ago, during which the patient had suffered from lip laceration and fracture of anterior teeth. Laceration in the lip was sutured immediately and later root canal treatment and crown placement was done. He further added that, 2 years after the trauma, he had developed pain and swelling in the upper lip in relation to 11, 12. A minor surgical procedure was done and a tooth spicule was removed. Constitutional signs and review of all systems appears to be normal on general examination. On local examination, inspection revealed no abnormality in the upper lip, labial mucosa and the entire oral cavity. On palpation a painful tiny hard mass measuring about 5 mm approx was palpable in the upper lip 0.5 cm lateral to the midline in relation to 11 and 12. On hard tissue examination prosthetic crown was present in relation to 11, 12. Considering the chief complaint, history and correlating with the clinical findings the mass in the upper lip was provisionally diagnosed as a foreign body in the upper lip. A 43 year old male patient came to the department of Oral medicine and Radiology with the chief complaint of pain in the upper lip for the past 15 days. The patient experienced a mild, intermittent, dull aching type in the same regionAn intra oral Periapical radiograph of the upper lip revealed a single radiopaque mass measuring about 3 X 2 mm in size .Blood investigation was performed which revealed to be within normal limits. Then an excisional biopsy was done by placing a single incision under local anesthesia . All procedures were performed under aseptic condition . thday, first month, third month and after 6 month. All necessary check radiographs were taken. The wound healing was satisfactory.A review was done after 7Histopathological examination shows the connective tissue mass with interspersing trabeculae of mature bone and osteocytes in lacunae surrounded by loose to densely arranged collagen fibers ). Hence the final diagnosis was suggestive of osseous Choristoma. Intra oral Choristoma are rare. As per literature there are only 72 cases in tongue mostly situated near the foramen ceacum around the circumvallated papilla, 15 cases in the buccal mucosa, one in palate and one in labial mucosa. T.s. Bastian et al, described a case of Choristoma of the labial mucosa and the etiology was given as unknown. Here we unfold a different presentation of Choristoma in the upper lip. The most probable etiology in this case could be a reactive lesion due to trauma (Intra oral osseous Choristoma is histologically a clear mass of lamellar bone with the haversian canals around a tight fibrous connective tissue covered with stratified epithelium. Choristoma has to be differentiated from that of a hamartoma, which is a focal overgrowth of haphazardly arranged cells at the normal site of origin. Teratoma is another condition where all three germ layers are mostly involved and presented in non-indigenous location . OsteomaThe history of trauma led us to give a diagnosis of foreign body of the upper lip initially. The histological report is characteristic to that of osseous Choristoma. Another reason for excluding the diagnosis of foreign body is the presence of trauma history before 15 years and the absence of multinucleated giant cell histologically. Surgical excision is the treatment of choice for osseous Choristoma. Malignant transformation has not been reported yet. There is no evidence of recurrence is mentioned in the literature .This case report presents a case of osseous choriostoma involving the upper labial mucosa. Surgical removal is the treatment of choice based on site, size and accessibility. Recurrence is uncommon.