Fetus in fetu is an extremely rare condition wherein a malformed fetus is found in the abdomen of its twin. This entity is differentiated from teratoma by its embryological origin, its unusual location in the retroperitoneal space, and the presence of vertebral organization with limb buds and well-developed organ systems. The literature cites less than 100 cases worldwide of twin fetus in fetu.A two-and-a-half-month-old Asian Indian baby boy had two malformed fetuses in his abdomen. The pre-operative diagnosis was made by performing an ultrasound and a 64-slice computer tomography scan of the baby's abdomen. Two fetoid-like masses were successfully excised from the retroperitoneal area of his abdomen. A macroscopic examination, an X-ray of the specimen after operation, and the histological features observed were suggestive of twin fetus in fetu.Fetus in fetu is an extremely rare condition. Before any operation is carried out on a patient, imaging studies should first be conducted to differentiate this condition from teratoma. Surgical excision is a curative procedure, and a macroscopic examination of the sac should be done after twin or multiple fetus in fetu are excised. Fetus in fetu (FIF) is a rare condition associated with abnormal embryogenesis in a diamniotic, monochorionic pregnancy, wherein a vertebrate fetus is enclosed within the body of another normally developing fetus . The FIFAn FIF is rarely found in the central nervous system, gastrointestinal tract, retroperitoneum, vessels or genitourinary tract of its host twin. It is found even more rarely in the lungs, adrenal glands, pancreas, spleen or lymph nodes . Even wiIn most cases of FIF, only one fetus exists inside the baby. Only in extremely rare cases are multiple fetuses found.A two-and-a-half-month-old, first-born, Asian Indian baby boy was admitted to the department of Pediatric surgery, S.S hospital, BHU, due to recurrent episodes of vomiting and abdominal distension since he was one month old. Upon examination of the baby's abdomen we discovered that a smooth, firm and non-tender mass was present in the left half of his abdomen. Conventional X-ray of the abdomen showed a soft tissue mass with a vertebrae-like column Figure . An ultrWe performed an elective laparotomy after correcting the baby's fluid and electrolyte levels. We then found a well-encapsulated cystic retroperitoneal mass that was displacing his spleen, transverse colon and pancreas. This displacement presented laterally and caudally toward his cephaloid and left kidney Figure . The masThe sac contained two miniature fetuses connected to each other by a cord-like structure at the umbilicus. The miniature fetuses had a well-defined foot, skin with hairs, a convex and pliable skull bone, and other undifferentiated tissues Figure . A radioA microscopic examination showed that the underdeveloped twin had mature embryonic tissues containing elements of the three germinative layers. Skin, a vertebral column, germinative buds of limbs, central nervous tissue , a stomach, small and large bowels, pancreas, adrenal glands, kidneys, upper and lower airways, cardiac striated muscles, and lymphoid tissue-like spleen were found. The histopathological study of the specimen supported the conclusion that the previously imaged calcifications could be assumed to be the skull and bony constituents of the vertebral axis, some parts of the skull, and bony constituents of the rudimentary limbs.Our patient recovered well after the surgery and was discharged. To rule out any recurrence he was followed up through clinical examination, plain abdominal X-ray examination, abdominal ultrasound, and serum alpha-fetoprotein (AFP). We were unable to detect any recurrence of his previous symptoms one year after the operation.The term "fetus in fetu" was first used by Johann Friedrich Meckel during the late 18th century . Subsequet al. reported that FIF occurs equally among the male and female populations [This rare pathology occurs only once every 500,000 births . Fewer tulations . In 70% ulations . The masulations , the saculations  and the The presence of a vertebral column in the FIF is an important feature that distinguishes it from a teratoma. The clear identification of a verterbal column shows that fetal development of the included twin had advanced at least beyond the primitive streak stage (12 to 15 days of gestation) to a notochord, which is the precursor of the vertebral column ,8. FIF get al. [The pre-operative diagnosis of FIF depends on its related radiological findings. Plain abdominal X-ray examination may prove helpful, as up to half of reported cases show the presence of a vertebral column and axial skeleton , which wet al.  discusseSonographic findings are usually those of a complex cystic mass with ill-defined solid internal components. Imaging continues to play an important role in diagnosing FIF. CT and MRI have been proven to be very helpful in suggesting a pre-operative diagnosis . In our Although the prognosis for FIF is more favorable than for cystic teratoma, the presence of immature elements nevertheless indicates the need for close clinical, radiological and serological (AFP) follow-up . DespiteAlhtough it is rarely the conclusive diagnosis, FIF should still be considered in a child presenting with progressively increasing abdominal swelling and vomiting. Although definitive diagnosis is best made using CT and MRI techniques, plain X-rays and ultrasonography can still be useful in the initial work-up prior to surgery. Post-operative X-ray examination of a specimen from the mass can ultimately confirm the diagnosis of FIF. The mass, however, should still be examined for the occurrence of multiple fetus even after it has already been excised.Written informed consent was obtained from the parents of our patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.ANG, SPS and PS operated on our patient and reviewed the literature. DKG and VK were the main moderators of the manuscript. All authors read and approved the final manuscript.


Trichobezoars are caused by hair ingestion. The usual presentation of a trichobezoar is with early satiety and malnutrition. Obstructive symptoms and manifestations of gastric outlet obstruction may occur. The diagnosis may be suspected in young females with malnutrition, who have a history of trichophagia.We report a case of 12-year-old female admitted to the emergency room for abdominal pain. On physical examination, she was cachectic and an epigastric mass was palpated. An exploratory laparotomy was conducted. A giant trichobezoar was palpated in the stomach and was removed through an anterior gastrostomy.There were no complications postoperatively and the patient was referred to a psychiatrist. Bezoars are incompletely digested food or fibrous materials that may cause intestinal obstruction over the time. Common clinical symptoms include abdominal pain, nausea, vomiting, weight loss . TrichobA 12 year old girl was admitted to our emergency department with 5 days history of abdominal pain and non-bilious vomiting. On physical examination, patient was cachectic and an epigastric mass was palpated. Biochemical results were normal except mild anaemia. X-ray depicted that stomach was dilated with no air-fluid level. Ultrasonography (USG) revealed hyperechoic mass on the epigastric region. On the computed tomography (CT) appearance, there was a heterogenous lesion from stomach to horizontal duodenal part that causes distation with circumcised air trapping (Figure The term bezoar was derived from the Persian word 'panzeh' meaning 'antidote' . In anciCommon presenting symptoms are abdominal pain, nausea, vomiting, weight loss, malnutrition, hematemesis, diarrhoea or constipation. On physical examination epigastric mass may be palpated. Alopecia may also be present due to trichotillomania.USG and CT imaging features are helpful in diagnosis. On the USG, bright echogenic band and shadow over the left upper quadrant may exist. CT demonstrates heterogenous, mottled intraluminal mass with low attenuation and air trapping .Phytobezoars may be digested enzimatically but trichobezoars are generally resistant to that treatment. Small gastric bezoars can be removed endoscopically. Large gastric trichobezoars can be removed either endoscopically or by laparotomy. In our case, a giant bezoar had caused duodenal obstruction. Small intestinal obstruction is rare but small intestine examination is important for ensuring about any other mass remnant.Since recurrences could occur, the patient must be directed to psychiatric follow-up after the operation.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.The authors declare that they have no competing interests.IY and RA analysed and interpreted the patient data. OVO and ES performed the literature review, and was a major contributor in writing the manuscript. OVO and IY performed the final editing of the manuscript. All authors read and approved the final manuscript.


Seborrheic keratoses, a benign growth lesion, is a very common cutaneous lesion encountered in white races in the fourth and fifth decade. The occurrence of this lesion on the vulva is rare, as an isolated lesion or in association with lesions elsewhere. A 34-year-old woman reported with a hyperpigmented palpable lesion, approximately 5-10 mm in diameter, was found on the patient's left labium majus. The clinical differential diagnosis of the pigmented lesions of the vulva is difficult often need a biopsy. Seborrheic keratoses (SK) are common benign pigmented lesions on the light-exposed skin in white races, generally believed to be readily identifiable clinically, but in some cases, the differential diagnosis between pigmented SK, malignant melanoma and genital wart is difficult, in particular in the vulva ,2.A 34-year-old woman referred to the gynecology clinic with a complain about vulvar irritation due to a pigmented vulvar lesion. The patient reported that it had been present for approximately 1 year. On clinical examination, a hyperpigmented irregular palpable lesion, approximately 5-10 mm in diameter, was found on the patient's left labium majus Figure . The patThe vulva is a histological combination of skin and mucous membranes components. Pigmented vulvar lesions, including diffuse hyperpigmentation, are present in 10 to 12% of white women . Some ofDermoscopy is an useful method for the differential diagnosis of pigmented lesions even in the vulva. However, it is technically difficult and uncomfortable to use dermoscopy specially in this particular site. With the development of digital image systems with smaller and easy to handle probes this difficulty is overcomed . DermoscThese vulvar SKs are composed of cytologically bland, basaloid cells that do not exhibit koilocytotic atypia but do exhibit hyperkeratosis, papillomatosis, acanthosis, variable melanin pigmentation, and horn pseudocyst formation . There iAssessment of pigmented vulvar lesions necessitate sophisticated examination. The vulvar region must be carefully inspected by dermatologists and gynecologists. Moreover genital region must be included. Vulvar biopsies are suggested in suspicious lesions due to probability of malign melanoma.To conclude, we think that in the differential diagnosis of vulvar pigmented lesions it should be keep in mind rarely this pigmented vulvar seborrheic keratoses.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 rewiev from the journal's Editor-in-Chief.The authors declare that they have no competing interests.EAK performed first medical exam reviewed the literature and wrote the manuscript. CG and ES consultated the patient and took the biopsy. HK revisied the manuscript for important content. All authors read and approved the final manuscript.


Purpose. Tumors of the perivascular epithelial cell tumor (PEComa), first described in 1992, represent a rare soft tissue neoplasm of varying malignant potential. Cases of PEComa have been previously described in a few somatic and visceral sites, most notably in the gastrointestinal tract, genitourinary tract, and one extremity case in the thigh. To date, most malignant cases of PEComa have been resistant to chemotherapy, and as such, an appropriate therapy is not known. Case report. Here we describe the first case of PEComa of the upper extremity. Open biopsy revealed a high-grade malignant lesion, and the patient subsequently underwent both neoadjuvant therapy with doxorubicin, ifosfamide and mensa, and radiation therapy prior to wide surgical resection.After six cycles of chemotherapy, the tumor underwent an 80Conclusion. Given the favorable albeit partial response seen in this patient, the course of therapy outlined here may represent a good starting point for neoadjuvant treatment in a tumor with a historically bleak prognosis. In addition, the diagnosis of PEComa must now be entertained in the differential diagnosis of upper extremity soft tissue sarcoma. Perivascular epitheloid cell tumor,or PEComa, is a rare soft tissue tumor characterized by cells epitheloid inmorphology with clear or eosinophilic cytoplasm, and a perivasculardistribution. Immunohistologically,PEComa is defined by positive staining for the melanocytic marker HMB-45 andsmooth muscle actin (SMA), but negative staining for melanocytic marker S100and variable staining for MelanA. First described in 1992 by Bonetti et al. . PEComa In this article, we present thefirst reported case of a PEComa of the upper extremity. We also report an encouraging response todoxorubicin-ifosfamide (Dox-Ifos), allowing for a more manageable definitivetreatment with tumor excision.A 49-year-old female presented inApril 2004 with a mass on the back of her right shoulder and complaints ofworsening pain with activity and decreased ROM. The patient underwent MRI and CT imaging of her right scapula whichrevealed an abnormal 5.3 × 4.7 cm soft tissue mass in the posterior medialaspect of the infraspinatus muscle. see  The massThe patient began neoadjuvanttherapy in May 2004, receiving six cycles of doxorubicin and ifosfamide(Dox-Ifos) between 5/10/04 and 9/10/04. Postchemotherapy MRI revealed an 80.1% decrease in size of the tumor to3.3 cm × 1.5 cm. Subsequently, thepatient underwent preoperative radiation therapy of the effected areaconsisting of five treatments per week for five weeks between 10/19/04 and11/24/04 for a total of 5000 cGy. PostradiationMRI revealed an increase in the size of the mass of 45.5% to 4.0 cm × 1.8 cm see.Limb sparing wide resection of theshoulder mass was performed on 12/20/04. Examination of the pathology specimen confirmed the diagnosis ofmalignant PEComa, with negative margins. The specimen revealed only 20% necrosis at the time of removal.On followup four months after thelast chemotherapy treatment, the patient showed no evidence of disease onMRI. The patient's chief complaint ofarm pain continued to improve. The patient exhibited no constitutional symptomsand was advised to continue to followup with repeat MRI of the scapula and Ctof the chest every three months for the first two years. The patient has no local recurrence thirteenmonths postresection (as of 1/06), but she did have a solitary lung mass on herchest CT at that same time. This lung mass excised fourteen months afterremoval of her primary lesion and was confirmed to be a metastasis.PEComas are soft tissue tumorsdefined by their unique expression of both melanocytic and smooth muscle cellmarkers. Radial arrangement of epithelioid cells around a vascular lumen ischaracteristic in these tumors, although there can be variation in the relativeproportion of epithelioid versus spindled cells. The group of tumors that sharethis “perivascular epithelioid cell (PEC)” nature is heterogeneous and includesthe following: lymphangiomyomatosis, pulmonary and extrapulmonary clear cellsugar tumor, clear cell melanomyocytic tumor, and abdominopelvic sarcoma of theperivascular cells, perivascular epithelioid cell tumor (PECT) . This tuFor our patient, doxorubicin,ifosfamide, and mensa were used as neoadjuvant therapy. These agents have been shown in numerousstudies to be among the most efficacious in the treatment of adult soft tissuesarcoma –17. Over


A 15 years old patient was taken to the operative room for an explorative laparotomy due to abdominal pain and a pelvic spleen at preoperative computed tomography: was pointed out the absence of all splenic ligamentous attachments and short gastric vessels with a consequently dislocation of a bigger and congested spleen in the pelvis. This organ, wrapped in the omentum, was in a serious ischemic suffering due to a 720 degrees clock torsion around its exceptionally long pedicle (about 20 cm); besides was confirmed pancreatic body and tail ectopy. Following the derotation, the volume of the organ has decreased but became fixed in above norm dimensions. A total splenectomy was executed. On abdominal sonography, no spleen could be demonstrated in the normal position; the left upper quadrant was filled with bowel loops. An enlarged spleen extending from lower-polar region of the left kidney to the pelvis was seen. A large hypoechoic area was seen, suggestive of infarction, with a streak of perisplenic fluid. Ultrasonography demonstrated no blood flow in the splenic vein and in the splenic artery. Subsequent contrast-enhanced CT scan also showed absence of the spleen in the left upper quadrant as well as an enlarged spleen in the left lumbar and iliac region. The splenic parenchyma showed poorly, inhomogenous enhancing areas suggestive of infarction. The splenic vein was dilatated and showed a non-enhancing filling defect near the hilum, indicating the presence of a thrombosis. The splenic vessels, pancreatic tail, and the surrounding fat formed a whorled appearance, supermedial to the splenic hilum, that was suggestive of torsion.A 15 year old otherwise healthy Caucasian male student  presented to the Emergency Department with a 24 hours abdominal pain and increase of his abdominal girth. The pain was non-continuous, poorly localized, and was non-colicky and non-radiating in nature. There was no history of vomiting, bowel or urinary symptoms. Over the prior 2 months, he reported one other similar episode that had resolved spontaneously. He was afebrile and his vital signs were stable. Abdominal examination revealed marked diffuse abdominal tenderness and guarding. A large hypogastric abdominal mass was palpable. Urinalysis and urine culture were normal; he had a white cell count of 19.4 × 10The patient underwent exploratory laparotomy through a midline incision. This revealed the absence of all splenic ligamentous attachments and short gastric vessels with a consequently dislocation of a bigger and congested spleen in the pelvis. This organ, wrapped in the omentum, was in a serious ischemic suffering due to a 720° clock torsion around its exceptionally long pedicle (≈ 20 cm); besides was confirmed pancreatic body and tail ectopy Figure . FollowiA wandering spleen is a rare but well-known entity. The incidence is < 0.2%. It is more common in females than males in an adult population . Acute, The clinical presentation of a wandering spleen can be variable. Affected patients may be asymptomatic and this condition may be discovered incidentally as an abdominal mass on physical examination or on imaging for other unrelated reasons. Patients may have mild intermittent abdominal pain due to splenic congestion with intermittent torsion and spontaneous detorsion, or may present with an acute abdomen due to torsion of the splenic pedicle with subsequent infarction. With acute torsion, the condition can be confused with appendicitis or ovarian torsion. Other clinical symptoms include nausea, vomiting, fever, leukocytosis, peritoneal signs, and a palpable mass in the abdomen or pelvis .For the definitive diagnosis of a wandering spleen, various imaging techniques, including plain radiography, barium enema, scintigraphy, gray-scale sonography, Doppler ultrasonography, CT, and angiography have been used .Historically, splenectomy has been the treatment for symptomatic wandering spleen. With increasing appreciation for the importance of the spleen in reticuloendothelial function, there has been renewed interest in splenopexy. However, in cases of splenic torsion with infarction, splenectomy is required. Attention to vaccination for encapsulated organisms should be performed, usually 1 to 2 weeks after splenectomy .Written informed consent was obtained from the patient's mother 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.The authors declare that they have no competing interests.EM recorded the patient data and took the photos. RM and LM performed the intervention, and FF was the major contributor in writing the manuscript. All authors read and approved the final manuscript.


A case of xanthogranulomatous salpingitis (XGS) associated with a large uterine leiomyoma in a 50-year-old woman is presented. Xanthogranulomatous inflammation is an uncommon form of chronic inflammation that is destructive to affected organs. It is characterized by the presence of lipid-filled macrophages with admixed lymphocytes, plasma cells, and neutrophils. A review of the literature revealed that most patients with XGS have a clinical history of long-standing pelvic inflammatory disease (PID) or, less often, endometriosis. We report a case lacking a history of either PID or endometriosis but with a concurrent large uterine leiomyoma. Although the exact etiology in this case was not clear, the leiomyoma may have played a contributory role in pathogenesis. Xanthogranulomatous inflammation is a form of chronic inflammation that is destructive to the normal tissue of the affected organs. It is characterized by the presence of a large number of lipid-containing macrophages with an admixture of lymphocytes, plasma cells, and neutrophils. Multinucleated giant cells may be present –4. Multiβ-HCG screen, were noncontributory.A 50-year-old, gravid 4, para 4, woman was evaluated for abnormal uterine bleeding. Her LMP was 6 months prior, and she was in otherwise good health. She had no history of endometriosis or PID and never used an IUD. She had a prior tonsillectomy and appendectomy, and her family history was unremarkable. She had a pelvic ultrasound that showed her uterus to be bulky and heterogeneous, containing a posterior uterine leiomyoma. Routine laboratory tests, including a Physical exam revealed an ectocervical polyp. The uterus was also markedly enlarged with a second-degree uterine prolapse as well as a cystocele and rectocele. Endocervical curettage was performed, and the polyp was sent for histology. The patient was advised to proceed with a total abdominal hysterectomy, possible bilateral salpingo-oophorectomy, and possible anterior and posterior enterocele repair. She was prescribed Marvelon (estrogen and progestin combination pill) to control her bleeding prior to the surgery. Total abdominal hysterectomy and left salpingo-oophorectomy were performed. The uterus was found to be bulky, globular, and mobile and enlarged to the size of a 14-week gestation. The left ovary was adherent to the left broad ligament posteriorly; at the time of surgery, this was thought to be due to inflammatory adhesions or endometriosis. On close examination, the left fallopian tube was swollen, resembling hydrosalpinx or hematosalpinx. The rest of the abdomen and pelvis were normal to inspection and palpation. The procedure was tolerated well, and the patient was discharged two days later.Gross examination of the specimen revealed a large, bulky uterus with serosal adhesions. On sectioning, the posterior myometrium showed a large 5.7 cm submucosal leiomyoma; the remainder of the uterus and cervix were unremarkable. The left fallopian tube was adherent to the ovary at its distal end and was distally enlarged to a caliber of 1.8 cm. Transection of the fallopian tube in this region revealed a thickened and fibrotic muscular wall with scanty hemorrhagic luminal contents. The ovary proper was unremarkable with the exception of a small follicular cyst.Histopathology of the cervical polyp proved it to be benign. The fallopian tubes showed infiltration of the lamina propria by large numbers of histiocyte with a mixture of inflammatory cells, including lymphocytes, plasma cells, and occasional neutrophils . There wXanthogranulomatous inflammation is characterized by the presence of numerous, foamy, lipid-rich histiocytes and other inflammatory cells . This unA review of the literature revealed fourteen cases of fallopian tube involvement reported to date , 11–16. The exact pathogenesis of xanthogranulomatous inflammation remains debated. Many unrelated disorders may have the same mechanism of foam cell production; proposed causes are infection, ineffective antibiotic therapy, abnormality in lipid metabolism, endometriosis, and ineffective clearance of bacteria by phagocytes. Predisposing conditions for the development of XGS include PID, the presence of an IUD, endometriosis, and inborn error in lipid metabolism by macrophages, unsuccessful antibiotic therapy, and radiotherapy –10. A coXGS needs to be distinguished from PXS, also known as pseudoxanthomatous salpingiosis, which is an equally rare phenomenon and occurs mainly in women with a long history of endometriosis. PXS is characterized by numerous histiocytes containing brown lipofuscin (ceroid) pigment within the lamina propria. In our case, the lack of lipofuscin pigments and the presence of other inflammatory cells support the diagnosis of XGS.Our patient presented with symptoms compatible with a submucosal leiomyoma. Lack of response to medical management of her menorrhagia led to a surgical hysterectomy, during which there was an operative suspicion of endometriosis because the left ovary was adherent to the left broad ligament. The patient did not have any history of a lipid metabolic disease, nor did her history give an indication of immunodeficiency. There was no evidence of endometriosis histologically; however, the fibrotic thickening with hemorrhage in the fallopian tube may be attributed to chronic inflammation. However, burnt out endometriosis can not be entirely excluded. Previous reports have suggested that xanthogranulomatous inflammation is probably initiated by a chronic obstructive and/or an ischemic process; this has been the experience of studies looking into xanthogranulomatous inflammation of the genital tract, kidney, and gall bladder . It is p


Lymphangiectasis usually occurs in the viscera. Involvement of the lower limb is very rare. It is difficult to establish the diagnosis without detailed investigations. Clinical features are peculiar and may mimic lymphoedema of different origins which needs to be ruled out. Contrary to the expectation, the post-operative result is excellent in the long-term follow-up. Lymphangiectasis means dilatation of lymphatic channels. It is commonly encountered in pulmonary, intestinal and retroperitoneal tissues. The involvement of a lower limb is very rare. Although few simulating cases have been reported, their clinical presentation as well as the surgical outcome were different from the present one. We have encountered a case that posed a difficult diagnostic puzzle. However, after thorough investigations, we established the diagnosis as Lymphangiectasis by excluding the other differential diagnoses, e.g. lymphoedema, lymphangioma and lymphangiomatoses. Staged excision of the lesion led to an excellent outcome without any recurrence after 3 years.A 20-year-old man presented with multiple lobulated growths of the right lower limb, lymphorrhea and disparity in limb girth. In the first 12 years of life, the limb was proportionate. Thereafter, for next 8 years, the right lower limb overgrew progressively which was painless. There were intermittent episodes of infection which subsided with antibiotic therapy and local care. The patient became physically and socially handicapped and lost his job. On inspection, the right lower limb below knee and dorsum of foot had multiple lobulated masses mimicking grade IV lymphoedema. The skin over the swelling was rugouse with dark pigmentation. The sole was spared. There was another lesion in the upper thigh extending to the groin. The lower two-third of the thigh was spared Figure –c.On palpation, it was soft, non-tender, compressible and non-pulsatile . There wThe differential diagnoses in our mind were lymphoedema, lymphangioma, lymphangiomatosis and lymphangiectasis. The patient was subjected to detailed investigation. The MRI of lower limbs and pelvis showed an extensive mass involving predominantly the subcutaneous tissue of right thigh with retroperitoneal extension. There was encasement of femoral and iliac vessels . MR angith day. After 6 months, the groin lesion was excised. No attempt was made to excise the retroperitoneal mass.A two-staged excision was planned for the leg and thigh separately. The below knee lesions were excised from the dorsum of foot, ankle and pretibial region by three individual incisions. Soon after incision, straw-coloured lymph started flowing freely. About 2 liters of fluid was completely squeezed out. There was hardly any delineation of subcutaneous tissue from dermis to deep fascia. Every structure was replaced by a dense, dilated network of lymphatic channels Figure ,b. It waThe histopathology of the excised specimen confirmed it to be lymphatic tissue with interconnected, dilated lymphatic spaces . On reguLymphangiectasis means dilatation of lymphatics with collection of excess lymph. It usually involves viscera e.g. lungs, intestine or retroperitoneum, the later manifest in the form of chyluria.–3 There Most cases of lymphangiectasis have extensive visceral involvement and poor prognosis. In this variant, it is limited almost exclusively to soft tissue of the lower limb and has good prognosis. This rare case posed unpredictable diagnosis with excellent surgical outcome.


Lobular capillary haemangioma is a rare vascular lesion of the nose. It is the aim of this communication to highlight the importance of considering this lesion as an important differential diagnosis of bleeding lesion in the nasal cavity.A case report of a 41-year-old female who presented with an obstructive, bleeding, pedunculated left nasal mass arising from the nasal septum in the anterior nasal cavity. An initial diagnosis of squamous papilloma was made and she had excision of the mass done under local anaesthesia. Tissue histology revealed lobular capillary haemangioma. The patient has been followed up for over 15 months and is still free of the lesion.To the best of our knowledge, this is the first report in the literature of lobular capillary haemangioma in the nasal septum in West Africa. The case is reported due to the rarity of this lesion in our environment. Lobular capillary haemangioma is a benign vascular neoplasm which commonly affects the skin, mucosal of the oral cavity and tongue ,2. NasalThe patient is a 41-year-old teacher, Yoruba by ethnic origin and Nigerian, who presented with a 3-week history of progressive, painless, left nasal growth associated with blood-stained left-sided nasal discharge and nasal blockage. This was preceded by nasal pricking. No excessive sneezing, nasal itch or fever. No pre-morbid history of nasal intubation, instrumentation or packing.No other rhinologic, otologic or dental symptoms were present.She had initial treatment at a secondary health institution where test aspiration of swelling was done two weeks prior to presentation with the disappearance of the swelling, the aspirate was bloody. However it recurred within a week thus necessitating the referral to our center.There was no associated intercurrent medical condition or surgical operation. She does not snuff tobacco.Clinical examination revealed a fit-looking middle-aged woman, not pale and afebrile.The nasal pyramid appeared normal. However, there was an obstructive left intranasal reddish brown, ulcerated polypoid mass which was attached to the anterior aspect of the tnasal septum by a pedicle. The mass was sensitive to touch and bled easily on contact Figure .Examination of the ears, oral cavity, oropharynx and the neck revealed essentially normal findings.An initial assessment of left nasal septal mass most likely a squamous papilloma was made.Her packed cell volume was 36% and her clotting profile was within normal limit. A plain paranasal sinus radiograph revealed a roundish area of lucency with sclerotic (opaque) rim in the left nasal cavity. The paranasal sinuses appeared clear and normal.She had a per-nasal excision biopsy under local anaesthesia and haemostasis was secured with digital pressure application on the nasal pyramid.Histology report showed polypoidal fragments of tissues lined by stratified squamous epithelium with focal ulceration. The underlying stroma is composed of proliferating thin walled capillary channels arranged in lobular fashion. The stroma is infiltrated by acute and chronic inflammatory cells. This was conclusive of a Lobular Capillary Haemangioma Figure .She has been followed up for more than a year with complete healing of the site without any recurrence.Nasal lobular capillary haemangioma, otherwise called pyogenic granuloma, is a rapidly growing benign vascular lesion which should now be considered in the differential diagnosis of a unilateral bleeding lesion in the nasal cavity.The actual incidence of this condition in West Africa may not be known as it is a well known fact that hospital statistics in developing countries is a poor index of the true incidence of a disease condition. Many patients in both rural and urban areas of West Africa do not present to hospitals for sundry reasons ranging from cost of health care to distance from health facility. Increased awareness of this condition among healthcare practitioners is important in identifying the disease. It would also be necessary to send every excised lesion from the nasal cavity for histological diagnosis; this may lead to the identification of more cases of Lobular capillary hemangiomas and thereby show the true incidence of the disease.Lobular capillary haemangioma is usually known to affect the skin and mucous layer of the oral cavity, while nasal involvement is rare . The disThe clinical presentation of this lesion in the nasal cavity is similar to what other researchers have reported ,4-8]. T. T8]. ThA high index of suspicion is required in making the diagnosis. Although this lesion affects the anterior aspect of the nasal septum more commonly as seen in our patient, it has been reported in other endonasal sites which include the vestibule, middle turbinates and posterior part of the septum -5]..5].Review of literature has implicated micro-trauma from nasal packing and intubation as the most common predisposing factors -7]. Oth. Oth7]. The recurrence of this lesion is uncommon and no malignant transformation has been reported (-11]). T). T11]).The surgical intervention carried out on the patient was that of a pernasal excisional biopsy under local anaesthesia which was sufficient for making histologic diagnosis as well as treating this patient as the mass was quite accessible on anterior rhinoscopy Figure .Lobular capillary haemangioma is a rare neoplasm which should be considered in the differential diagnosis of rapidly enlarging vascular lesions within the nasal cavity. Pernasal excisional biopsy of the lesion under local anaesthesia is sufficient for making histologic diagnosis as well as treating this patient.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.The authors declare that there is no conflicting interest.AJF was the principal investigator and the conceiver of the idea for publication. He also performed the excision of the nasal mass. The literature search and the writing up of the manuscript were done by OSA and AJF. AAA is the owner of the patient and he revised the manuscript and supervised the patient's management. CAO prepared and reviewed the slide and the microfilm.


Lipoma and angiolipoma are common benign neoplasms that occur in the subcutaneous tissue and rarely in the gastrointestinal tract. These tumors are usually asymptomatic but may present with abdominal pain, bleeding and obstruction. We present a 53-years-old woman with abdominal discomfort for several weeks accompanied with bloody diarrhea and recurrent vomiting. Ileo-ileal invagination was diagnosed by computed tomography scan. Laparotomy revealed five intraluminal masses that caused intussusception. Histopathological study showed that one was angiolipoma and other lesions were lipoma. We have described some aspects of diagnosis and treatment of this rare cause of intestinal intussusception. Lipoma and angiolipoma may develop as a benign tumor in all organs and rarely in large or small intestine. The majority of lipomas in the small bowel are solitary. Approximately 5% are multiple . AngioliA 53-years-old Iranian woman was admitted to the emergency department in a tertiary referral hospital with 4 months history of intermittent upper abdominal pain accompanied with nausea and bloody diarrhea. She also had history of obstipation and constipation. These symptoms were aggravated in the recent two weeks. In past medical history, there was only a history of hysterectomy 11 years ago. There was no familial history of any disease, with no significant habitual history. In physical examination, the abdomen was distended and tender. Results of routine laboratory examinations were within normal limit. Abdominal X-ray showed dilated loops of small intestine which was indicated an obstructive pattern . After rIntussusception occurs when a segment of intestine invaginates into itself. Intussusception accounts for about two percent of bowel obstructions in adults. In adults, intussusception is more likely to present insidiously with vague abdominal symptoms and rarely presents with the classic triad of vomiting, abdominal pain and passage of blood per rectum, making diagnosis difficult. Intussusception can be confidently diagnosed on CT scan because of its virtually pathognomonic appearance. On CT scan, intussusception appears as a “sausage-shaped” mass in the longitudinal axis, and as a “target” mass in the transverse axis. In contrast to children, more than 90% of intussusceptions in adults have a demonstrable cause, 60% due to neoplasm . The high rate of pathologic lead points, along with the high rate of malignancy, makes surgery mandatory in these cases .The lipomas are rare benign tumors, representing 2.6% of non malignant tumors of the intestinal tract . Most ocAngiolipoma was demonstrated by Bowen in 1912 for the first time. Howard and Helwig described its clinicopathological characteristics in 1960. Since then, angiolipoma has been regarded as a new entity . AngioliThe diagnosis of intussusception in our patient was suggested by clinical features, abdominal X-ray and CT examination. After segmental resection of ileum, we found five intraluminal masses. The histopathological findings of these masses revealed both an angiolipoma and lipomas as rare causes of intussusception.Angiolipoma and lipoma are rare benign neoplasms of gastrointestinal tract, most of them are asymptomatic and found incidentally; but may produce symptoms such as obstruction and bleeding. Surgical resection remains the treatment of choice and produces an excellent prognosis.


Lower gastrointestinal hemorrhage accounts for approximately 20% of gastrointestinal hemorrhage. The most common causes of lower gastrointestinal hemorrhage in adults are diverticular disease, inflammatory bowel disease, benign anorectal diseases, intestinal neoplasias, coagulopathies and arterio-venous malformations. Hemangiomas of gastrointestinal tract are rare. Mesenteric hemangiomas are also extremely rare.We present a 25-year-old female who was admitted to the emergency room with recurrent lower gastrointestinal bleeding. An intraluminal bleeding mass inside the small intestinal segment was detected during explorative laparotomy as the cause of the recurrent lower gastrointestinal bleeding. After partial resection of small bowel segment, the histopathologic examination revealed a cavernous hemagioma of mesenteric origin.Although rare, gastrointestinal hemangioma should be thought in differential diagnosis as a cause of recurrent lower gastrointestinal bleeding. Lower gastrointestinal hemorrhage is defined as an abnormal intraluminal blood loss from a source distal to the ligament of Treitz. Lower gastrointestinal hemorrhage can be due to numerous conditions, including diverticulosis, anorectal diseases, benign or malignant neoplasias, inflammatory bowel disease, and angiodysplasias. Coagulopathies can also be the cause of lower gastrointestinal bleeding. Although hemangiomas can be seen in liver, osseous tissues, mediastinum, soft tissues and other organs, intestinal hemangiomas of mesenteric origin are extremely rare.We report a case of mesenteric hemangioma of small intestine causing lower gastrointestinal bleeding.A 25-year-old female was admitted to the emergency room with fatigue, recurrent black stools. She was hospitalized because of gastrointestinal hemorrhage. Profuse anemia with a hemoglobin level of 4.4 g/dl and the hematocrit 17% was detected. Three packs of red blod cell were transfused immediately. She did not have obvious hematochesia The upper gastrointestinal endoscopy did not show any bleeding lesion. An antral gastritis was only detected during the gastroduodenoscopy. Double contrast barium enema was also normal. We canceled the previously scheduled colonoscopic examination after detecting a 5 × 4 cm sized abdominal mass in the small bowel mesentery through abdominal computed tomography (Figure Histopathologic examination of the resected specimen revealed a cavernous hemagioma of mesenteric origin Figures , 3.It is generally believed that hemangioma is a congenital hamartomatous lesion that originates from embryonic sequestrations of mesodermal tissue -5. HemanGastrointestinal hemangiomas arise from the submucosal vascular plexuses and may invade the muscularis layer. There is rarely penetration beyond the serosa . GastroiThe symptoms of hemangioma depends on the localization of the primary tumor. Eighty percent of patients with gastrointestinal hemangiomas presents with symptoms such as bleeding or obstruction ,8. The mHemangiomas may result in hemoperitoneum or intestinal obstruction due to the intussusception of the polypoid tumor. Whereas abdominal pain may become the major complaint in these patients, nausea, vomiting, and abdominal distention may also be found -11. The Gastrointestinal hemangiomas of well-defined segment of intestinum are usually suitable for surgical resection at the time of diagnosis ,11. RecuLow-dose radiation therapy, cryotheraphy, brachytheraphy, sclerotheraphy or arterial embolization has been used in nonresectable and diffuse hemangiomatosis with limited success ,13.Whereas preoperative definitive diagnosis of a mesenteric hemangioma is nearly impossible, oral and intravenous contrast enhanced computed tomography could be helpful in suspecting and localization of such a lesion. Surgical resection of the involved segment remains as the treatment of choice for suitable cases.As a conclusion, mesenteric hemangioma may be the cause of recurrent lower gastrointestinal bleeding manifested with anemia, and/or episodes of abdominal pain. Although it is very rare, gastrointestinal hemangioma should be kept in mind after eliminating the more common causes of gastrointestinal hemorrhage in differential diagnosis.The authors declare that they have no competing interests.MK, MU and CI planned and wrote the manuscript. CI translated the manuscript to English. MU collected the datas. NO and FY performed the histopathologic evaluation. GE, MZ, MK and AC analyzed the present data and made the revisions.


A CT guided FNAC was inconclusive. Open biopsy and hemilaminectomy of L5 vertebra was performed. Histopathology and immunocytochemical analysis revealed it to be primitive neuroectodermal tumor. Patient was given chemotherapy and radiation therapy. His lower limb power improved by grade I post operatively and at 2 years follow-up bowel/bladder recovery was noticed. Patient died after 2.5 years of surgery because of pulmonary metastasis.A 24-year-old male patient presented with cauda equina lesion symptoms. His clinicoradiological examination including X-rays, CT scan and MRI revealed destruction of L Primitive Neuro-Ectodermal Tumor (PNET) is a small round cell tumor of neural crest origin, typically seen in second or third decades of life. These are highly malignant tumors, sharing the morphological, histochemical and immunogenetic features with Ewing sarcoma.135A 24-year-old male presented with a four-month history of progressive low back pain. He had fever, loss of appetite and significant loss of weight in the preceding four months and had already completed four months of antitubercular therapy as advised by a local physician who diagnosed the entity to be Pott’s spine of L5 vertebra. On clinical examination of the back we noticed a soft tissue swelling in the lumbar region measuring about 10 × 8 cm in dimensions. It was tender, warm; but nonmobile and nonpulsatile. On neurological examination he had, power around knee and ankle joint 3/5 grade motor, with diminished ankle and knee reflexes and bowel bladder incontinence.Laboratory parameters revealed normal blood count with significantly raised erythrocyte sedimentation rate (ESR=68 mm/hr), alkaline phosphatase (ALP=528 U/L) and lactate dehydrogenase (LDH=355 U/L). Liver, Renal, Thyroid function and calcium profiles were all within normal range.Radiograph and Computed tomography (CT) revealed marked destruction of L5 vertebra, extending to left pedicle and the left lateral elements. There was a left posterior extraosseous, paraspinal soft tissue component measuring 7 × 6 cm. On Magnetic Resonance Imaging (MRI), the mass had increased intensity on T2 and decreased intensity on T1 weighted images . The lesIn view of progressive neurological deficit and inconclusive CT guided biopsy, open biopsy was planned with simultaneous extensive posterior decompression and stabilization. However, because of excessive bleeding from the tumor mass, the procedure could not be completed and was limited to left sided hemilaminectomy of L5 vertebra.The microscopic picture of the biopsy specimen showed tumor cells comprised of small round cells arranged in solid sheets and nests with formations of true rosette. The tumor cells had hyperchromatic nuclei with scanty cytoplasm Figure , b. A feAfter the surgical procedure, the patient had grade one power improvement on left side with mild subjective improvement in numbness; but the bowel-bladder incontinence persisted. MRI of the brain was found to be normal and hence the possibility of drop metastasis was excluded. He was further managed by radiation-oncologist and was administered multiagent chemotherapy  and locally fractionated dose external beam radiotherapy . After a two-year follow-up, the patient had complete sensory and bowel-bladder recovery with motor power of 4/5 around ankle and foot. Six months later, he died of respiratory complications because of pulmonary metastasis.Irrespective of its origin , the clinical picture, treatment and complications of spinal PNET remains same. Most of these cases present with history of progressive increase in back pain and neurological deficit. Radiography of vertebral PNET typically shows destructive lesion of the spine, sometimes associated with a soft tissue mass.The lack of specific clinico-radiological features bring many primary differential diagnoses into consideration i.e.; Ewing sarcomas, osteosarcomas, neuroblastomas, lymphomas and leukaemias, chordomas, hemangoimas, aneurysmal bone cysts and giant cell tumors etc.Histological diagnosis in the form of fine needle aspiration cytology or open biopsy is essential to reach the diagnosis. PNET can be differentiated from other small round cell tumors, including lymphomas, by neural differentiation and immunocytochemical staining techniques.12988et al, in their review of literature of 28 cases of spinal PNET found that 11 patients (39.3%) died at follow up period of 20 months.et al. reported the average time from operation to death was 18.1 months.Ozdemirpatients 9.3% diedThough rare, PNET of spine is an important consideration in patients presenting with low back pain with soft tissue lump. Histology with immunocytochemical staining is essential for confirmation of diagnosis. Despite an aggressive management, the overall prognosis remains poor,231112


Adenocarcinoid of the appendix is a rare malignant tumour with features of both adenocarcinoma and carcinoid, showing both epithelial and endocrine differentiation. Mucinous cystadenoma is the commonest of the benign neoplasms of the appendix, with an incidence of 0.6% in appendicectomy specimens. We report a rare combination of these tumours and discuss the latest treatment options. To the best of our knowledge, only six cases have been reported in the literature to date.A 71-year-old Caucasian man presented to our department with a right iliac fossa mass associated with pain. Laparoscopy revealed an adenocarcinoid of the appendix in combination with mucinous cystadenoma. He underwent a radical right hemicolectomy with clear margins and lymph nodes.Adenocarcinoids account for 2% of primary appendiceal malignancies. Most tumours are less than 2 cm in diameter and 20% of them metastasize to the ovaries. The mean age for presentation is 59 years and the 5-year survival rate ranges from 60% to 84%. Right hemicolectomy is generally advised if any of the following features are present: tumours greater than 2 cm, involvement of resection margins, greater than 2 mitoses/10 high-power fields on histology, extension of tumour beyond serosa. Chemotherapy mostly with 5-Fluorouracil and Leucovorin is advised for remnant disease after surgery. Cytoreductive surgery with intraperitoneal chemotherapy can offer improved survival for advanced peritoneal dissemination. Mucinous cystadenoma is the commonest of the benign neoplasms of the appendix, with an incidence of 0.6% in appendicectomy specimens . AdenocaA 71-year-old man presented to the surgical department with a 2-week history of colicky right iliac fossa pain and a 1-week history of diarrhoea. He did not have rectal bleeding or weight loss. On examination, he was found to have a right iliac fossa mass. Serum carcinoembryonic antigen (CEA) was <2 μg/L and the computed tomography (CT) scan revealed an appendiceal mass , extension of tumour beyond serosa, lymphovascular invasion or lymph node metastases ,13. Someolectomy .Chemotherapy mostly with 5-Fluorouracil and Leucovorin is advised for remnant disease after surgery. Cytoreductive surgery with intraperitoneal chemotherapy can offer improved survival for advanced peritoneal dissemination . In femaWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AV contributed in the conceptualization and design of the manuscript, literature search, data acquisition and manuscript preparation. SS was involved in data acquisition, illustration and manuscript preparation. JG contributed in the design of the manuscript, data analysis, editing and manuscript review. JS was involved in the literature search, data acquisition and revising the manuscript critically for content. SB contributed to the drafting of the manuscript, literature review, editing and was the clinician responsible for making the treatment decisions for the patient. All authors read and approved the final manuscript.


Fournier gangrene is a rare necrotising fascitis of the perineum and genitals caused by a mixture of aerobic and anaerobic microorganisms. The first case was described by Baurienne in 1764 but the condition was named by Fournier in 1883 who reported the cases of five men with the condition with no apparent etiology. Infection most commonly arises from the skin, urethra, or rectal regions. Despite appropriate therapy, mortality in this disease is still high. We report a case of a low rectal malignancy presenting as Fournier gangrene. This case report serves to highlight an extremely unusual presentation of rectal cancer, a common surgical pathology.The patient is a 48 years old Afghanian male that admitted with Fournier gangrene. In the course of medical and surgical treatment the presence of extensive rectal adenocarcinoma was discovered. After partial recovery, standard loop colostomy was inserted. Skin grafting of necrotic areas was performed and systemic rectal cancer chemotherapy initiated after full stabilization.Fournier gangrene is an uncommon but life threatening condition with high associated mortality and morbidity. Usually there is an underlying cause for the development of Fournier gangrene, that if addressed correctly, can lead to a good outcome. Early diagnosis and treatment decrease the morbidity and mortality of this life threatening condition. Good management is based on aggressive debridement, broad spectrum antibiotics and intensive supportive care. The patient is a 48-year-old Afghanian male that referred to our center due to swelling, redness and tenderness of external genitalia, that found incidentally in the investigation of cachexia and weigt loss. He revealed no genitourinary or gastrointestinal complaints before admission. After admission full physical examination performed.On examination, patient was cachectic with BMI of 18 kg/m2. He was afebrile and initial hematological investigations revealed only a moderate leucocytosis  with mild anemia (Hg 11 g/dl). External genitalia and perianal examination revealed skin necrosis, pussy drainage and subcutaneous crepitations, in addition to above mentioned signs.Urgent and vigorous intravenous triple antibiotic therapy with Ceftriaxone (2 grams Q 12 h), Metronidazole (500 mg Q 8 h) and Amikacin (500 mg Q 12 h) was commenced. He was taken to operating room, multiple times, and every time vigorous debridement performed. A thorough washout was performed. Following acute management a thorough examination including digital rectal examination was performed which detected an extensive rectal mass with extension of necrotic points to the anal area. Punch anal biopsy performed and sent for histological analysis, which showed rectal adenocarcinoma. The zone of necrosis covered a large area from external genital area to the inner aspect of right thigh to the right side of the abdomen (Figure Systemic chemotherapy for the treatment of underlying rectal adenocarcinoma initiated, the patient was well one year after first visit.Fournier gangrene is a rapidly progressive necrotizing fasciitis of the perineum and external genital organs. The first documented clinical picture of the disease was made by Fournier in 1883. Its epidemiology has changed and is much different from the origin. It affecting mostly men between 50 and 60 years of age. This disease also affects females. It is uncommon in pediatric age group and little is known about the disease in the newborn period and infancy . The mosIn a large population based epidemiologic study, 1641 males and 39 females with fournier gangrene identified. Cases represented less than 0.02% of hospital admissions. The overall incidence was 1.6/100,000 males, which peaked in males who were 50 to 79 years old. The overall case fatality rate was 7.5% . For preNecrotizing fascitis of the perineum and genitalia is a severe condition with a high morbidity and mortality. It seems that there are no major differences between male and female patients in the characteristics of the condition . Good maWritten 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.The authors declare that they have no competing interests.MMK is the corresponding author and responsible for the surgery, SGMA assisted in surgery and editing the manuscript, MAA and AA were major contributors in writing and editing the manuscript. All authors read and approved the final manuscript.


Neoplasms arising from Meckel's diverticulae reported in the literature are mainly carcinoid tumours, gastrointestinal stromal tumours, and gastric or intestinal adenocarcinomas.We describe a 50-year-old man who presented with rectal bleeding and anaemia, later found to be caused by a pancreatic adenocarcinoma arising from ectopic pancreatic tissue in a Meckel's diverticulum. The tumour was unfortunately highly aggressive, and the patient passed away within 5 months of symptom onset.We believe this is the first case of pancreatic adenocarcinoma in a Meckel's diverticulum to be reported in the literature. The diagnosis of Meckel's should be considered in patients with acute gastrointestinal complaints; when found incidentally at laparotomy, it should be carefully examined for any gross abnormality and resection should be considered. Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, affecting approximately 2% of the population ,2. It isA 50-year-old man presented with a 4-week history of rectal bleeding with associated dyspnoea on exertion. His past medical history was unremarkable and there was no significant family history. He was a non-smoker and a social drinker. Physical examination including a digital rectal examination was unremarkable.Initial investigations revealed a hypochromic, microcytic anaemia with a haemoglobin level of 8 g/dl and a ferritin level of 4 μg/L. Biochemical assessments of liver and renal functions were normal. Gastroduodenoscopy was normal and colonoscopy only revealed an incidental 2 mm benign tubular adenoma in the rectum.Cross-sectional imaging was carried out. A MRI enteroclysis Figure  revealeden bloc appendicectomy was carried out and an omental deposit was sampled for histological assessment.A laparotomy was carried out via a grid iron incision. A Meckel's diverticulum was found to be adherent to the tip of the appendix in the right iliac fossa. There was a primary tumour arising from the Meckel's diverticulum and multiple sub-centimetre peritoneal deposits in the adjacent visceral peritoneum. These deposits were further distributed in the parietal peritoneum on the right side of the true pelvis and as tiny granular deposits in the greater omentum. A Meckel's diverticulectomy and Gross examination of the specimen revealed a 40 mm diameter tumour arising from the mucosal aspect of the bowel wall of the Meckel's diverticulum. The tumour directly involved the peritoneal wall, and had invaded the serosal surface of the small bowel. The resection margins and the adhered appendix were tumour-free. A single omental deposit submitted separately was also involved by the tumour.Histology of the tumour Figure  showed tThe patient made good post-operative recovery. He was discharged following multi-disciplinary discussion among surgeons, radiologists and oncologists, with detailed out-patient follow-up arrangements in place, including an outpatient appointment with the pancreatic oncology specialist within a week of discharge.Two weeks following discharge however, he developed food intolerance and small bowel obstruction was confirmed on CT scan. A second laparotomy was carried out and a dramatic increase in the volume of tumour was encountered Figure  with a sSubsequent management was palliative and the rapid tumour progression continued until his death some 6 weeks after the initial operation.Meckel's diverticulum was first described by Fabricus Hildanus in 1598 , and wasPatients with Meckel's are usually asymptomatic, and the diverticulae are invariably discovered incidentally at autopsy, laparotomy or laparoscopy. These patients have a 2–4% lifetime risk of developing complications from it ,2,4. ComHeterotopic pancreatic tissue itself is uncommon, with reported frequency between 0.55 to 13.7% ; the majThe authors however, are not advocating incidental diverticulectomy in every patient found to have a Meckel's. Soterro and Bill have reported that up to 800 incidental diverticulectomies are required in order to save one life , and theAlthough Meckel's and its complications are not common, the possibility of a Meckel's diverticulum and its potential complications should be considered when faced with a common gastrointestinal complaint and negative initial investigations. When found incidentally at laparotomy or laparoscopy, it should be carefully examined for any gross macroscopic abnormality and resection should be considered, especially in young male patients who are more likely to develop complications from it or patients who might have had previous symptoms attributable to it.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.The authors declare that they have no competing interests.HK and BP reviewed the literature and wrote the case presentation. CB and IB described the histological findings and confirmed and edited the manuscript. SB provided radiological images and confirmed the manuscript. DG conceived the case report, helped draft and revised the manuscript. All authors read and approved the final manuscript.


A 45-year-old white male presented to our department with postoperative recurrence of gastrointestinal poorly differentiated neuroendocrine carcinoma manifesting as lymph node dissemination and a solitary implantation metastasis in the rectovesical pouch. Following disease progression on chemotherapy, the patient was treated with radiotherapy using either a conventional daily treatment or an accelerated hyperfractionated protocol to separate sites of disease progression. Using serial CT scan assessment, changes in cross-sectional area of the separately treated metastatic lesions were evaluated for determination of therapy response. The accelerated hyperfractionated radiotherapy appeared to limit the rate of tumor growth to a greater degree than the conventional fractionation schedule. Of uttermost importance, in this palliative setting, the patient completed the intensified radiotherapy regimens with acceptable acute toxicity. Given the proliferative capacity of poorly differentiated neuroendocrine carcinomas of the gastrointestinal tract, radiotherapy may be a therapeutic supplement to chemotherapy, which represents the main treatment option in this tumor entity. Importantly, tumors with a capacity for rapid proliferation and regeneration may be particularly sensitive to the use of intensified fractionation protocols in clinical radiotherapy. Radiotherapy is typically administered by fractionated schedules to allow normal tissue recovery from sublethal damage between each treatment fraction. However, surviving tumor cells also proliferate during the interfraction periods, and in addition, accelerated repopulation is a recognized contributor to treatment failure. The rate of repopulation often increases with time during radiotherapy treatment, and accelerated fractionation protocols have therefore been suggested as potentially advantageous by shortening the overall treatment time . MoreoveUndifferentiated small-cell carcinoma of the gastrointestinal tract represents a rare tumor entity and may originate in any site within the gastrointestinal tract. Most patients either present with or rapidly develop disseminated disease. Traditionally, surgery has been a significant treatment option in locoregionally limited disease, although many patients ultimately have systemic relapse. These tumors are generally highly sensitive to chemotherapy, but in extensive disease, responses to chemotherapy are usually of short duration, and progression after first-line therapy is often aggressive . AvailabA 45-year-old white male, never-smoker, presented to a local hospital with a 1-month history of intermittent bleedings per rectum. His medical background was unremarkable. Lower endoscopy revealed an ulcer in the terminal ileum adjacent to the ileocecal valve, and the patient proceeded to resection of the terminal ileum and right hemicolon. Histological examination  and cisplatin  in 4-week cycles  located between the abdominal aorta and inferior vena cava and a lesion with peripheral contrast enhancement and decreased central density (19 mm × 32 mm in the transverse view) located in the rectovesical pouch. Because of waiting time until admittance, a new CT scan was performed , confirming an additional ≥ 2-fold increases of cross-sectional lesion area  using anterior-posterior radiation fields Figure . This paGiven that nodal tumor masses are regular ovoid structures that show proportional changes in all dimensions, measurements of bidimensional tumor size  are fully in accordance with volumetric measurements when assessing treatment response . MoreoveIn extrapulmonary small-cell carcinomas, no randomized trials are reported to guide patient management, and few data exists on patient outcome after radiotherapy. Given the rarity of these tumor entities, treatment approaches have typically been extrapolated from trials designed for limited-stage small-cell lung carcinoma ,11. As oIn this patient, the independent courses of accelerated hyperfractionated radiotherapy to the retroperitoneal and supraclavicular nodal sites appeared to result in a greater degree of tumor control when compared to the conventional daily fractionation course delivered to the pelvic recurrence. The 2-Gy Biological Equivalent Dose delivered by the intensified fractionation schedules equals 44–48 Gy, and the patient was able to complete both of the intensified radiotherapy regimens with acceptable acute toxicity. This aspect, together with the advantage of a reduction in overall treatment time, are critically important objectives of optimized radiation oncology care in the palliative therapy setting.The author declares that she has no competing interests.AHR conceived of the patient's treatment and management, supervised chemotherapy administration and radiotherapy treatment planning and accomplishment, performed interpretation and clinical approval of the radiologic assessments throughout the treatment course and for this presentation, and conceived, prepared, and approved the manuscript.Histology of the primary tumor surgical specimen. The figure is displayed in PDF format. The panels represent sections with hematoxylin and eosin staining (left column) or immunohistochemical staining for Ki67 (right column) and depict an ileal, transmural small-cell carcinoma containing nests of abnormal tubular and glandular structures and with a high fraction (90%) of Ki67-positive tumor cells.Click here for fileAbdominal CT scan 364 days after the diagnosis of disease relapse. The figure is displayed in PDF format. The images were generated by multislice CT technique (with the liver parenchyma in contrast-enhanced portovenous phase), and the two representative images in transverse view (left) and reconstructed image in coronal view (right) display retroperitoneal lymph node metastases (M) located between the abdominal aorta and inferior vena cava. The round structure located adjacent to the left kidney was a parapelvine cyst, which remained unaltered throughout the disease course.Click here for filePelvic MRI examination 492 days after the diagnosis of disease relapse. The figure is displayed in PDF format. The two representative MR images are oblique and T2-weighted and display the tumor (periphery indicated by arrows) located in the rectovesical pouch, infiltrating into the posterior wall of the bladder (B) and the urethral lobe of the prostate (P). Tumor extension to the anterior rectal wall was observed on an accompanying CT scan.Click here for file


Our aim was to review the current literature describing the endoscopic management of upper tract transitional cell carcinoma (TCC).Review of published, peer-reviewed articles relating the primary ureteroscopic or percutaneous management of upper tract TCC was performed using the MEDLINE database.Historically, the gold-standard management for upper tract TCC consists of nephroureterectomy with excision of a bladder cuff. The employment of endoscopic management with these neoplasms was initially instituted in individuals with imperative indications, including bilateral disease, solitary kidney, and/or renal insufficiency. For individuals treated with ureteroscopy, recurrence rates range from 30 to 71% and cancer-specific survival rates from 50 to 93%. Results are dependent primarily on tumor grade and stage. In individuals with low-stage, low-grade tumors treated percutaneously, recurrence rates, and cancer-specific survival rates are 18-33% and 94-100%, respectively. Adjuvant therapy has been employed with thiotepa, mitomycin, and BCG, but none have been able to demonstrate a statistically significant difference in recurrence or cancer-specific survival rates.Endoscopic management is a safe and effective treatment alternative to nephroureterectomy in the management of upper tract TCC. Survival outcomes are comparable, but renal preservation therapy offers the advantage of reduced morbidity, complications, and the potential for better quality of life. Recurrence and disease progression are not uncommon and underscore the need for strict tumor surveillance. Upper tract transitional cell carcinoma (TCC) is relatively uncommon, accounting for 5-10% of renal tumors and 5% of all urothelial cancers.1 Upper trWith the development of flexible ureteroscopes, improved optics, and small diameter laser fibers, endoscopic renal preserving treatment is feasible for upper tract TCC. Initially, endoscopic management of ureteral and renal pelvis TCC was reserved for individuals with imperative indications, including bilateral disease, solitary kidney, or renal insufficiency. However,Initial presenting symptoms may vary, but hematuria is the most common, either gross or microscopic and is present in 75% of individuals. This is The utility of voided urine cytology is limited as it is nonspecific. However, even with the use of selectively obtained ureteral cytologies, the diagnostic yield is still only 60% accurate. ImprovedUreteroscopy provides a valuable tool in the evaluation of upper tract TCC. With the advancement in optics, flexible ureteroscopes and endoscopic equipment, visualization, and sampling of the tumor has improved. The greatest prognostic factors in the management of upper tract TCC are pathologic grade and stage. Histologic correlations of up to 90% have been established between the initial ureteroscopic biopsy and the final pathologic specimen. However,Retrograde ureteroscopic management of upper tract UC provides the advantage of reduced morbidity, the ability to perform the procedure on an outpatient basis, and the maintenance of a closed urinary system. The limitations of ureteroscopy, however, are secondary to the instrument size, which allows for a smaller field of view, smaller working channel, and the size of tumor that may be effectively resected. In addition, location of tumor in the lower pole of the renal pelvis is not always reliably accessible and prior urinary diversion may make retrograde access challenging.There are multiple methods by which upper tract TCC may be treated endoscopically. However, regardless of the method, adequate tissue sampling, and abdominal imaging should be obtained first to rule out the presence of grade 3 and/or T2 disease, both of which are contraindications to endoscopic management. Ureteroscopic biopsies may be performed using a variety of endoscopic instruments. Tumor biThe principles of treatment are similar to those for endoscopic resection of bladder tumors. Effective tissue sampling should be obtained for pathologic diagnosis and subsequent ablation of residual tumor should then be performed. Tumor resection to its base may be accomplished with an ureteroscopic resectoscope in the distal ureter. This differs from bladder tumor resection in that only intraluminal tumor is removed and no attempt is made to obtain deep tissue. Proximal lesions are less amenable to this technique due to the design of the rigid ureteroscope. Alternatively, the lesion may be treated with electrocautery. The use of high cutting current may be used when the lesion is nearly circumferential to reduce the development of scar tissue and subsequent stricture formation. More recently, upper tract lesions in the ureter and renal pelvis have been treated with the neodymium:yttrium-aluminum-garnet (Nd:YAG) and the holmium:YAG (Ho:YAG) lasers. A combinThe endoscopic approach to managing upper tract TCC was first employed in patients with imperative indications, including bilateral disease, solitary kidney, or renal insufficiency with creatinine >2.0 mg/dl. Upper tr1820Due to enhanced technology and increased experience, the role of endoscopic management has become increasingly utilized, even in the presence of a normal contralateral kidney.24 For in202620Patients with a history of bladder TCC represent a distinct cohort at increased risk of developing upper tract recurrence. Prior investigation has demonstrated that prognosis for patients who develop upper tract TCC after cystectomy is poor, with these individuals typically manifesting advanced disease. Studies 20One benefit of conservative therapy is that complication rates from ureteroscopic management are fairly low. Of treated individuals, 1-4% has ureteral perforation secondary to technical errors from guide wires, baskets, ureteroscopes, and/or laser fibers. Stricture rates vary from 5 to 25% in the published series1920 and 19The percutaneous approach to managing upper tract TCC is generally reserved for large renal and/or proximal ureteral tumors. Advantages of this approach include the utilization of larger instruments to enhance visualization, percutaneous access to facilitate adjuvant topical therapy, improved staging capabilities, and the ability to perform second-look nephroscopy. It avoids the limitations of flexible ureteroscopy and can reliably gain access to areas that are difficult to reach, such as the lower pole calyx or the upper urinary tract in patients who have undergone prior urinary diversion. Disadvantages include the increased morbidity compared with ureteroscopy and the theoretical risk for malignant seeding of the nephrostomy tract.Percutaneous access is obtained into the desired calyx and is described elsewhere. ApproachComplications from percutaneous management are more common than what is experienced from ureteroscopic approach and are similar to those experienced with treatment of benign renal disease. The most common complication is bleeding requiring transfusion and has been reported to be up to 50% in some series. This was33Outcomes of individuals treated with percutaneous resection of upper tract TCC strongly correlate with tumor grade. Jabbour and associates demonstrated a cancer-specific survival of 100, 94, and 63% for grades I, II, and III, respectively, in 54 patients treated percutaneously and is c32Adjuvant topical therapy has been investigated for treatment of upper tract TCC, similar to that performed with superficial bladder cancer. The most commonly used agents are mitomycin, thiotepa, and BCG. These agents are generally well tolerated and may be delivered percutaneously or in a retrograde fashion with a ureteral catheter following ureteroscopic resection. Adjuvant37The potential for frequent recurrences along with grade and stage migration underscores the need for strict postoperative surveillance for upper tract TCC. Patients undergoing endoscopic resection should be followed every 3 months for the first year after treatment. Chen andUpper tract TCC is an uncommon malignancy that poses a significant challenge to the practicing urologist. Symptoms at presentation are variable and some individuals will manifest hematuria or flank pain, although many are asymptomatic. The yield of diagnostic modalities continues to improve but may occasionally miss the diagnosis in certain circumstances secondary to the size of the lesion or the sensitivity of the study. Currently, CT urogram is the modality of choice for imaging the upper tract, but ureteroscopic evaluation is necessary for any suspicious lesions with subsequent biopsy.The gold-standard of therapy for upper tract TCC is nephroureterectomy with excision of a bladder cuff. However, other therapies exist and endoscopic resection has proven to be a safe and effective alternative in selective patients. These procedures are generally well tolerated and are associated with a fairly low risk for complications. Studies have demonstrated that endoscopic approach does not adversely affect overall patient survival. However, recurrences are common and may occur locally or in the bladder. Attempts to reduce recurrence risk with topical adjuvant therapy have been attempted with mitomycin, thiotepa, and BCG, but have not demonstrated a statistically significant reduction in recurrence rates. In addition to recurrence, the potential for tumor grade and stage migration are present. These findings underscore the need for strict tumor surveillance following resection and require an individual who is motivated and compliant with follow-up.


Cardiac inflammatory myofibroblastic tumor (IMT) is a rare entity and is associated with distinct clinical, pathological and molecular features. The clinical behavior, natural history, biological potential, management and prognosis of such tumors are unclear. We present herewith an adolescent girl who presented with similar entity involving the junction of the right atrium and the inferior vena cava (IVC) in association with thrombocytosis and IVC thrombosis leading to obstruction of blood flow. Diagnostic tools included imaging and immuno-histopathology studies. Surgical management included resection of the tumor and thrombo-embolectomy of the IVC under cardiopulmonary bypass. This case is unique due to association of complete obstruction of IVC caused by the strategic location of the tumor, thrombosis of vena cava and association of thrombocytosis. These features have not been reported yet in relation to the cardiac IMT. This report will help in better understanding and management of similar cases in terms of planning cannulation of femoral veins or application of total hypothermic circulatory arrest during cardiopulmonary bypass and prompt us to look for recurrence or metastasis during follow up using echocardiography and laboratory investigations. The possibility of IMT should be kept in the differential diagnosis of cardiac tumors especially in children and adolescents. Primary cardiac tumors are exceedingly rare in children and adolescents with a reported overall prevalence of 0.08% . MajoritA 14-year-old girl was referred to us for evaluation of a right atrial mass diagnosed incidentally in the referring hospital after an appendicectomy.The patient had pedal oedema and hepatomegaly. The laboratory tests revealed leucocytosis, thrombocytosis, and elevated liver enzymes. Two-dimensional echocardiography, computer tomography including magnetic resonance imaging of the chest showed presence of right-sided contrast-enhancing mass in the right atrium near IVC junction with a size of 35 × 38 mm in cross-sectional dimensions . In addiIn view of the severe obstructive features, possibility of tumor embolization and unknown nature of the cardiac mass, an urgent surgical intervention was undertaken under standard cardiopulmonary bypass. Intraoperative transoesophageal echocardiography confirmed the location of tumor within the right atrium . The canHistopathology of the tumor revealed presence of myofibroblasts, fusiform and spindle cells, modest inflammatory infiltrates, and myxoid stroma in the background of small lymphocytes, plasma cells, and eosinophils Figures . The immUsually, IMT involves lungs, liver, stomach, lymph nodes, retroperitoneal tissue, and spleen . World HThere are no specific signs or symptoms related to the cardiac IMT's, as these are related to the location within the heart. However, these tumors are thought to elaborate cytokines that may produce constitutional symptoms and signs such as fever, anorexia, anemia, hyper gamma-globulinemia, leukocytoclastic vasculitis, polyarthritis, and thrombocytosis , 3. The Surgical excision of the tumor has been the mainstay of the management, though radiotherapy, immunosuppressant, and chemotherapy have been tried as an adjunct to surgery without additional benefit . In our Cardiac IMT's are potentially benign lesions with favorable prognosis and should be considered in the diagnosis of cardiac tumors in children and adolescents. Surgical management is currently the preferred treatment approach. Although, recurrence or metastasis of cardiac IMT has not been reported yet, the followup of such patients should be aimed to monitor tumor recurrence which may be heralded by a return of clinical or laboratory abnormalities. Therefore, a physical examination, echocardiography, and blood tests for inflammatory markers, platelets count, and IL-6 levels are mandatory at regular intervals during long-term follow-up. In addition, patients should be informed about variable biological behavior and nature of this entity.


Spinal “stroke” is an uncommon cause of paraplegia. Spinal cord infarction from unruptured aortic aneurysm is rare. When encountered it poses diagnostic challenge to the clinician due to its rarity, which may lead to incorrect or delayed diagnosis. We report a case of 62-year-old man presenting to casualty as caudaequina syndrome due to spinal cord infarction secondary to emboli from an infra renal abdominal aortic aneurysm. To the authors knowledge this is first case of its kind and has not been reported in literature. Patient had improvement in proximal motor function following repair of the aneurysm, although he remained doubly incontinent in six months follow up. Spinal cord infarction is a rare clinical entity characterized by a sudden onset of paralysis, bowel and bladder dysfunction, and loss of pain and temperature perception, with preservation of proprioception and vibration sense . Spinal A 62-year-old Caucasian man, service engineer presented to accident and emergency with sudden onset of low back pain whilst lifting a washing machine at work. Pain radiated to groins and was associated with progressive bilateral weakness with numbness in the legs, with more marked symptoms on the left side. There were no cardiovascular symptoms, and the patient had normal observations. He was previously fit and well. He had no medications. He was a smoker for around 40 years and smoked twenty cigarettes a day. He was referred to the orthopedic team as a possible case of cauda equina syndrome secondary to a prolapsed intervertebral disc.Neurological examination revealed profound motor deficit in the legs with Medical Research Council (MRC) grade 2/5 muscle power in the hip flexors and complete paralysis in all other groups distally. All reflexes including the plantar reflexes were absent, and sensation was altered throughout both legs. Sensory and motor functions at level T12 were preserved. Perianal tone and sensation were both markedly reduced and he was unable to feel the passage of a bladder catheter. His vital signs were stable with normal pulse and blood pressure. Complete cardiorespiratory examination was normal and all peripheral pulses were palpable. However, abdominal examination revealed a nontender pulsatile mass.9/Lt. Lumbar puncture was unremarkable. His other blood parameters including LFT, Renal functions and bone profile were normal apart from slight raised cholesterol 6.2(5.3 mmol/lt). Plain radiographs revealed mild degenerative changes in the spine. An urgent MRI scan was requested to rule out caudaequina due to disc prolapse. An MRI revealed  and female sex are considered to be independent predictors of unfavorable outcome . The preSpinal cord infarction secondary to abdominal aortic aneurysm is a rare presentation of acute nontraumatic paraplegia. Thorough abdominal and vascular examination in is imperative for timely diagnosis. Cord infarction is a well-known complication of dissecting aortic aneurysms and aortic surgery but can arise into hitherto asymptomatic and untreated abdominal aortic aneurysm. MRI remains the investigation of choice in the acute setting to rule out the most common causes.


To report the occurrence of a rare case of a huge benign ovarian tumour (mucinous cystadenoma) in Jazan city, Saudi Arabia.Our reported case was a middle-aged Saudi woman presented with marked abdominal distension and discomfort at the gynaecology clinic of Jazan General Hospital, Jazan city, Saudi Arabia.The data were collected by history-taking, clinical examination, laboratory investigations, transabdominal ultrasonographic examination, and by histo-pathological study of the excised surgical specimen.The case was reported as a rare massive ovarian mucinous cystadenoma.This case report emphasizes the significance of thorough evaluation of all women presented with vague abdominal pains. Although the condition is extremely rare, it is a potentially dangerous in its massive form if not timely diagnosed and managed properly. With the increasing awareness of such conditions, more and more cases could be detected and reported early. As it contains mucinous fluid, its rupture leads to mucinous deposits on the peritoneum (pseudo-myxoma peritonei). This report presents a case of a giant ovarian mucinous cystadenoma in a Saudi woman, one of the biggest reported ovarian tumours in the medical literature.Ovarian mucinous cystadenoma is a benign tumour that arises from the surface epithelium of the ovary. It is a multilocular cyst with smooth outer and inner surfaces. It tends to be huge in size. Of all ovarian tumours, mucinous tumours comprise 15% . About 8A 29-year-old divorced Saudi woman presented with her parents at the gynaecology outpatients' clinic of Jazan General Hospital, Saudi Arabia, with a massive abdominal distension and discomfort. The patient has no living children from her previous marriage that lasted for 3 years. She was divorced one year back. Although the patient and her parents noticed gradual abdominal enlargement since 10 months back, they did not ask for a medical advice as they thought it was a pregnancy. As more than 9 months passed out without commencement of parturition, they consulted their general practitioner (GP) at the primary healthcare unit in their village. The GP suspected a huge abdominal tumour and referred the patient to Jazan General Hospital.The patient had no previous medical diseases or surgical operations. Her menarche commenced at the age of 13 years with subsequent irregular cycles. She denied the use of any medications.General examination revealed normal vital signs other than a slight tachypnea (Respiratory rate was 24/minute). Her body weight was 92 kg, her height was 162 cm and her abdominal circumference was 127 cm. Secondary sexual characters were evident. Previous exposure to burn during her childhood left old scars and depigmentation on her upper limbs. On abdominal examination, a huge ill-defined pelvi-abdominal mass was noticed, extended up to xiphisternum, with evident dermal striae. The abdomen was cystic tense on palpation without tenderness or shifting dullness . A plain chest X-ray on erect position was also done (Figure 5. A plaiGiant ovarian tumours have become rare in current medical practice, as most cases are discovered early during routine check-ups. Detection of ovarian cysts causes considerable worry for women because of fear of malignancy, but fortunately the majority of ovarian cysts are benign.sticky gelatinous fluid rich in glycoprotein. In a previous reported case [Mucinous cystadenoma is a benign ovarian tumour. It is reported to occur in middle-aged women. It is rare among adolescents  or in asted case , the tumHistologically, mucinous cystadenoma is lined by tall columnar non-ciliated epithelial cells with apical mucin and basal nuclei. They are classified according to the mucin-producing epithelial cells into three types . The firManagement of ovarian cysts depends on the patient's age, the size of the cyst and its histo-pathological nature. Conservative surgery as ovarian cystectomy and salpingo-oophorectomy is adequate for benign lesions . In our A written informed consent was obtained from her for publication of this case report and its accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The author declares no competing interests.This work was done by RMK and there is no contribution of any other authors.


Varices of the colon are a rare cause of lower gastrointestinal bleeding, usually associated with portal hypertension due to liver cirrhosis or other causes of portal venous obstruction. Idiopathic colonic varices are extremely rare. Recognition of this condition is important as idiopathic colonic varices may be a cause of recurrent lower gastrointestinal bleeding.We report the case of a 21-year-old Asian man from north India who presented with recurrent episodes of lower gastrointestinal bleeding. Colonoscopy revealed varices involving the terminal ileum and colon to the sigmoid. Thorough evaluation was undertaken to rule out any underlying portal hypertension. Our patient underwent subtotal colectomy including resection of involved terminal ileum and an ileorectal anastomosis.Colonic varices are an uncommon cause of lower gastrointestinal bleeding. Idiopathic colonic varices are diagnosed after excluding underlying liver disease and portal hypertension. Recognition of this condition is important as prognosis is good in the absence of liver disease and is curable by resection of the involved bowel. Varices of the colon are a rare cause of lower gastrointestinal bleed, usually associated with portal hypertension due to liver cirrhosis or other causes of portal venous obstruction. Idiopathic colonic varices are extremely rare. Recognition of this condition is important as idiopathic colonic varices may be a cause of recurrent lower gastrointestinal bleed.A 21-year-old Asian man from north India presented with history of recurrent episodes of lower gastrointestinal bleeding over the past six years. He had intermittent episodes, one to two per year, of passing bloody maroonish stools with occasional hematochezia. Episodes were self limited lasting two to three days, but required repeated hospital admissions with multiple blood transfusions. He had no significant past medical or family history of similar complaints. Physical examination was unremarkable. He was admitted with a fresh episode of lower gastrointestinal bleeding, which subsided spontaneously. Coagulation profile, liver function tests and hepatitis serology were normal. Upper gastrointestinal endoscopy to the third part of the duodenum did not reveal findings suggestive of portal hypertension or any other bleeding source. Colonoscopy revealed several large dilated tortuous sub-mucosal varices extending from the upper rectum, sigmoid, the entire colon extending into the terminal ileum (Figure At surgery his liver was normal and there was no evidence of portal hypertension. Intra-operatively, portal pressure measured by cannulating mesenteric veins was normal. Small bowel was normal except for the terminal 15 cm, which showed evidence of dilated tortuous sub-serosal vessels with a clear demarcation from rest of small bowel marked by a meandering dilated mesenteric vein Figure , confirmLower gastrointestinal bleeding is a frequent cause of hospital admissions. Common causes of lower gastrointestinal bleeding are diverticulae, vascular ectasia, colitis, non-specific caecal ulcers, neoplasia and proctal lesions . VaricesUsual presentation is recurrent massive bleed. The age at presentation has ranged from 18 years to 75 years with no sexual predilection -9. BleedTreatment options are conservative management and surgical resection. Conservative treatment alone has been attempted ,9; howevOur case highlights a rare cause of lower gastrointestinal bleed of which fewer than 20 cases have been reported in literature. Knowledge of this entity is important for the treating physicians as it is commonly confused with portal hypertensive varices. Identification of true idiopathic varices in such cases by a thorough workup has important prognostic and therapeutic implications.Colonic varices are an uncommon cause of lower gastrointestinal bleed. Idiopathic colonic varices are diagnosed after excluding underlying liver disease and portal hypertension. Family history of similar problem may be seen in some, but not all, cases. Recognition of this condition is important as prognosis is good in the absence of liver disease and is curable by resection of involved bowel.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the journal's Editor-in-Chief.The authors declare that they have no competing interests.RPK and RKS were involved in conceiving the study and drafting the manuscript. UCG was involved in revision of draft. All authors were involved the management of the patient, contributed intellectual content and have read and approved the final manuscript.


Extrahepatic portal vein aneurysm is a rare disorder. From 1956 to 2008, we found only 43 published English-language reports, including 67 cases, using Pub Med. We report a case of a 77-year-old woman who had complaints of lower abdominal fullness and residual urine. We performed ultrasonography (US), which demonstrated a congenital extrahepatic portal vein aneurysm. She had no obvious symptoms of the extrahepatic portal vein aneurysm. She had undergone gastrectomy without blood transfusion for gastric ulcer more than 20 years ago. Physical examination revealed no abnormal findings. US revealed a 2.2 × 1.8 cm, round shaped hypoechogenic lesion at the hepatic hilum. Color Doppler US showed bidirectional colors due to circular flow within this lesion. 3D-CT and CT angiography demonstrated that the saccular aneurysm at the hepatic hilum was 3.0 cm in diameter and was enhanced equal to that of portal vein.Twenty-six months after the diagnosis, the aneurysm had not grown in size. Since our patient had no serious complaints or liver disease, surgical procedures had not been employed. US and 3D-CT are noninvasive diagnostic techniques and are helpful in the diagnosis and follow-up of extrahepatic portal vein aneurysms. A 77-year-old Japanese woman had been hospitalized in our institute due to urocystitis. In September 2007, she was incidentally diagnosed with a congenital extrahepatic portal vein aneurysm after Ultrasonography (US) was conducted during an investigation for lower abdominal fullness and residual urine. She had undergone gastrectomy due to gastric ulcer without blood transfusion. Her family history was not particularly interesting. Physical examination revealed no jaundice, no abdominal mass, and no vascular noise. Routine blood tests did not show any remarkable findings. US revealed a well-circumscribed anechoic structure that was 26.4 × 21.7 × 19.4 mm in size at the porta hepatis Figures . Color DShe remained asymptomatic and returned to the hospital 26 months after the diagnosis for follow-up. The aneurysm showed no enlargement in size by follow-up CT and US after 27 months.Portal vein aneurysm (PVA) is an uncommon disease , 2. HoweThe origin of PVAs may be congenital or acquired . FormerlAbdominal US (including Doppler US) is useful and convenient for the diagnosis of PVA and has been used in most cases to date , 9, 34.