A 11-month-old, intact male, Rhodesian Ridgeback was presented to the Veterinary Teaching Hospital with signs of inappetence, lethargy, and abdominal pain for 3 days. A large and well-defined abdominal retroperitoneal mass, related with the left kidney, at the expected location of the adrenal gland, was revealed by radiography, ultrasound, and computed tomography. The mass extended caudally to the iliac artery bifurcation, compressing the aorta, caudal vena cava, and both kidneys. Cytology findings were compatible with a malignant round cell tumor. The most probable diagnosis was neuroblastoma. Following a comprehensive discussion with the owners about a treatment plan, surgical excision was performed. Because a wide excision would compromise major vessels, excision was performed after careful dissection of the aorta and vena cava. The left kidney was removed because the proximal ureter could not be separated from the tumor. The animal recovered successfully. Diagnosis was confirmed by histopathology and immunohistochemistry, but the owners decided not to pursue any further treatment. Clinical signs of abdominal pain recurred within 1 month following surgery. Therefore, the animal was euthanized upon the owners' request. This report describes the diagnosis, surgical treatment, and follow-up of a dog with an abdominal peripheral neuroblastoma. Neuroblastomas are tumors of neuroectodermal origin, arising from primitive sympathetic ganglion cells  . AlthougTo the best of our knowledge, there are no reports on any attempted treatment of peripheral neuroblastomas in veterinary literature. Additionally, prognostic information for neuroblastomas is scarce. In most cases, they were described and studied during diagnostic necropsy.This case report describes the detailed diagnostic work-up, attempted surgical excision, and short-term follow-up of an adrenal neuroblastoma in a young dog.An 11-month-old intact Rhodesian Ridgeback dog was presented to the Veterinary Teaching Hospital of the Faculty of Veterinary Medicine, University of Lisbon. The owners reported clinical signs of inappetence, lethargy, and presumed cervical pain which lasted for 3 days. There was no previous history of other diseases and vaccination and deworming were up-to-date.Clinical examination revealed slight abdominal pain and a large, palpable, mid-cranial abdominal mass with firm consistency. Cervical pain was not found and the neurological exam results were normal, except for a stilted gait of the animal, possibly due to abdominal pain. Blood samples were collected for hematology and biochemistry  and the results of these tests were within reference range. Abdominal and chest radiography, abdominal ultrasound, and thoraco-abdominal computed tomography (CT) were performed to identify and stage the mass .The mass was large and located cranially, causing ventral deviation of the intestine and spleen. No chest anomalies were identified on left and right lateral and ventro-dorsal projections. During ultrasonography, we identified a large retroperitoneal mass with irregular margins, located cranial to the left kidney, extending caudo-medially to the iliac artery bifurcation, and compressing the aorta and caudal vena cava. The mass had mixed echogenicity with underlying hypoechoic diffuse background with small scattered echogenic foci, possibly due to calcification. No thrombi of major vessels were identified. The left and right kidneys showed discrete pyelic dilations of 0.7 cm and 0.5 cm in diameter, respectively. This was attributed to the compressive effect of the mass. The liver and spleen appeared normal during ultrasonography. Fine needle aspiration was performed during the abdominal ultrasound. The cytological diagnosis was a malignant non-differentiated neoplasia, due to an abundant population of loosely arranged round to oval cells with marked anisocytosis and anisokaryosis. Nuclear indentations and multiple nucleoli were commonly seen.Pre- and post-contrast CT scans were performed using a Toshiba Astellion (16 slice-light speed) machine. Images were obtained using the helicoidal acquisition mode in a single phase, with 10-mm slices and reconstruction at 1 mm for the abdomen and 3 mm slices and reconstruction at 1 mm for the thorax, at 120 KV and 300 mA. The contrast medium was Ioxitalamate sodium . Analysis of the abdominal series was performed using the soft tissue algorithm  and that of the thorax was performed using the lung  and soft tissue  algorithms. Pre-contrast CT revealed a large lobulated (120.7 × 123.4 × 84.3 mm), heterogeneous soft tissue density mass, with irregular margins and mineralized foci, of unknown origin, located in the retroperitoneal space, extending from the level of the second to the sixth lumbar vertebrae. On the post-contrast study, the mass showed a moderate mixed contrast uptake pattern, with hypointense central areas, suggestive of necrosis or fluid intermixed with stippled calcifications . Slight The differential diagnoses at this point were lymphoma, adenoma, carcinoma, myelolipoma, pheochromocytoma, neuroblastoma, and ganglioneuroma. The clinical and cytological features of the mass and the young age of the animal were highly suggestive of an adrenal neuroblastoma. This was a large, unique abdominal mass originating in the retroperitoneal space, anatomically related to the left kidney. The left adrenal gland was absent, there were no signs of distant metastasis. Cytology revealed non-differentiated neoplasia . ConsideThe animal underwent exploratory laparotomy 7 days after initial presentation. Anesthesia was performed according to a multimodal protocol with intra-muscular administration of methadone  with acepromazine  as pre-medication, 30 min before induction. An intravenous catheter was placed in the cephalic vein. Induction was performed with intra-venous administration of midazolam  combined with Propofol  to allow intubation. Ketamine , fentanyl , and lidocaine  were administered throughout the procedure at a constant rate and during the 12-h post-operative period. Because the procedure was long, antibiotic prophylaxis was performed by administering cefazolin .Anesthetic monitoring was performed using a multiparameter monitor with electrocardiography, side stream capnography, pulse oximetry, and oscillometric non-invasive blood pressure and temperature monitoring. Non-invasive blood pressure monitoring was performed using the Doppler method  for accurate measurements.An abdominal ventral midline incision from the xiphoid to the pubis was performed to gain full access. The mass occupied most of the abdominal cavity. Inspection and palpation of other internal organs did not reveal signs of metastasis. The mass was primary, extensive, lobulated, and separated from peritoneal organs by the parietal peritoneum.Wide excision was not possible because this would result in resection of the major vessels at the attachment point. Consequently, the tumor was excised using a method previously described in humans . This teDissection of the left kidney from the mass was possible, but not the ureter. Dissection at the level of the hilus was attempted but was unsuccessful due to the gross anatomic distortion caused by the tumor. Therefore, as planned, a nephrectomy was performed .The retroperitoneal space was sutured using a 4/0 poliglecaprone suture in a simple interrupted pattern. Abdominal closure was performed in three layers: 2/0 and 3/0 poliglecaprone sutures were used to close the abdominal fascia, subcutaneous tissue, and skin, respectively. Transfusion was not performed as planned because intraoperative blood loss was approximately 7% of total blood volume and intraoperative blood pressures were maintained during the procedure .Postoperative management included constant infusion for 12 h, fentanyl transdermal patch , applied at the time of surgery, for 72 h, and meloxicam  once daily for 3 days. No major complication was identified, and the animal was discharged 3 days after surgery. Oral medication included Firocoxib , administered for 5 days. Mirtazapine  was prescribed once daily from the fourth day post-operation, due to the reduced appetite of the animal. The animal fully recovered 1 week later.Histopathology of the mass confirmed its neoplastic nature. Tumor cells were round to oval, organized in lobules within a poor stroma . Cell liThe adjuvant chemotherapy plan was refused by the owners. Thirty-three days after surgery and 40 days after initial presentation the owners returned reporting similar complaints. During clinical examination, the dog presented a stilted gait, associated with abdominal and lumbosacral pain. The owners refused to pursue any further investigations or treatments. The dog was subsequently euthanized upon their request.Post mortem examination revealed one enlarged nodule in the cranial mediastinum (60 × 25 mm). The central mesenteric lymph node was also enlarged (75 × 35 mm) together with numerous small hepatic nodules disseminated throughout the parenchyma (average diameter of 5 mm). No signs of macroscopic tumor recurrence were found at the surgical site. Histological examination confirmed the lesions to be metastasis of the adrenal neuroblastoma, similar to the results obtained through immunohistochemistry.In dogs, most neuroblastomas originating from the adrenal gland are not associated with any specific signalment. Symptoms range from asymptomatic to lethargic, weight loss, abdominal distension, and compression-related signs such as dyspnea, pain, ataxia, paresis, diarrhea, and edema , 5–8. SoThe biological behavior of this embryonal tumor in the dog resembles what is observed in children . To the Surgical excision was attempted as the principal approach to reduce size and increase the chance for chemotherapy control. Since a wide excision was not possible due to adhesion to major vessels, a technique described for treating similar tumors in humans was used . In the Sharp dissection between the adventitia and tunica media of the aorta and caval vein is possible and was successfully done in this case. However, there was one iatrogenic incident which led to rupture of the vena cava, which could be repaired successfully. With security maneuvers such as the use of tourniquets and elastics, the risk of hemorrhage during sharp dissection along major vessels can be controlled. In this case, the predicted intraoperative risks were based on the information provided by the CT and ultrasound, which included acute abdominal hemorrhage and the need to perform a left nephrectomy.The definitive diagnosis of neuroblastoma in the present case was based on histological features, immunohistochemistry results, and the young age of the dog. Tumors of the adrenal medulla, which arise from neuroectodermal cells of the neural crest, can differentiate into sympathetic nervous system or secretory cells. When the sympathetic nervous system cell line is adopted, the tumors may be very primitive neuroblastomas or more differentiated tumors formed by sympathetic ganglion cells, the ganglioneuromas. Neuroblastomas may also be formed by more primitive neural crest cells that have not differentiated yet . When thConsidering the high proliferation rate revealed by the Ki-67 immunolabeling, a high risk of recurrence rate was expected. The benefit of a combined treatment is unknown in dogs but chemotherapy was suggested based on treatment strategies in humans with neuroblastoma. The aim of adjuvant chemotherapy in children is to control any residual disease , 17. HowAbdominal and lumbosacral pain was again observed by the owners 33 days after the procedure. Pain associated with tumor progression  could be of neuropathic origin. The owners were not convinced of the benefits of pursuing further treatments. The animal was therefore euthanized upon their request. Post-mortem findings revealed metastatic spread to the lymph nodes and liver, but not the bone, which could have justified the origin of the perceived pain. Neuroblastoma can metastasize through the lymphatic or hematogenous route, affecting bone, liver, and noncontiguous lymph nodes . SimilarThis is the first report of surgical resection of a large adrenal neuroblastoma in a dog. We hope that this information will help others who may encounter similar cases.LM, MM, SJ, and MP drafted the manuscript, AF critically revised the manuscript, and HP substantially contributed to the study. All authors approved the final version of the manuscript.The patient was treated using the highest standards of care at our veterinary teaching hospital in all steps of diagnosis and treatment. We obtained the consent of the owner of the animal according to the teaching hospital policy.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Grynfeltt's lumbar hernia is a rare abdominal wall pathology with around 300 cases described in the literature. Recently, a therapeutically aimed classification was proposed analysing the size, location, contents, muscular atrophy, origin, and existence of the previous recurrence. Surgical repair is the only definitive treatment option through either an open or laparoscopic approach. An 87-year-old female came to consult for swelling in the right lumbar area without traumatic history. A smooth, reducible, and tender mass of 4 x 3 cm was described. The suspicion of a Grynfeltt's hernia was confirmed by lumbar ultrasound with evidence of a 10 mm abdominal wall defect with the diameter increasing to 15 mm during a Valsalva maneuver. The patient had a primary type A lumbar hernia; therefore, open hernioplasty was performed. The patient was discharged from the hospital on the third postoperative day in optimal clinical condition. Her 12-month follow-up examination was uneventful.A lumbar hernia diagnosis can be challenging. Preoperative imaging has an important role in assessing the size, location, and hernia contents. The use of a therapeutically aimed classification could be useful for optimal patient management and improvement of surgical outcomes. Secondam2; 10%) . Diagnosm2; 10%) , 8, 11. m2; 10%) . In factm2; 10%) . Differem2; 10%) . SurgicaAn 87-year-old female came to consult for swelling in the right lumbar area. The patient's past medical history was positive for a carotid aneurysm embolization, left hip prosthesis insertion, and multiple arthroses. A smooth, reducible, and slightly tender right lumbar mass approximately 4 x 3 cm was evident and a transmitted impulse could be felt during a cough. The lumbar swelling was reduced in the prone position. The suspicion for a Grynfeltt's hernia was confirmed by lumbar ultrasound (US) with evidence of herniation of a small intestinal loop through a 10 mm abdominal defect with a diameter increase to 15 mm during deep breathing. The patient was submitted to surgery under local anaesthesia. An open approach was performed. A lumbar transverse incision and a dissection of subcutaneous fat and the latissimus dorsi muscle fibres were performed in order to access the hernia sac (Figure LH is a relatively rare defect of the posterior abdominal wall with approximately 300 cases reported in the literature. LH can be divided into Grynfeltt's lumbar hernia and Petit's lumbar hernia Figure . LH diagLH requires a careful evaluation for the correct operative management. Computerized tomography of the abdominal wall is considered the gold standard for the diagnosis and evaluation of the hernia content; however, in our opinion, a US examination performed by a skilled radiologist was more adequate in our present case. The use of a therapeutically aimed classification is crucial for a correct evaluation of the patient and the decision for the most suitable surgical approach.


Primary pericardial tumours are very rare and are hence not usually part of our differential diagnosis, especially since they have non-specific signs and symptoms. While chest radiography remains the most common initial imaging investigation in the assessment of suspected cardiothoracic pathology, the diagnostic yield for assessing pericardial lesions is limited, often necessitating the need for further assessment with echocardiography, CT scan or MRI. We present a case of an adult male patient with an incidental primary pericardial tumour diagnosed during the routine imaging assessment of suspected pulmonary infections. After proper formulation of diagnosis, the patient was managed accordingly for pulmonary pathology and discharged on recovery. Over the years, with advancement and widespread increase in use of multidetector CT and MRI, diagnosing primary pericardial tumours has become easier. MRI has now become the modality of choice for imaging of pericardial tumours because of its better soft-tissue contrast resolution. Prevalence rate of primary pericardial tumours is low, approximately 0.02–0.056% with the tumours arising primarily from pericardium even rarer.A 61-year-old male patient presented to the Chest & Pulmonary Medicine outpatient clinic of our hospital with complaints of breathlessness, cough and fever for a fortnight. Fever was low grade, continuous and decreased on taking medication, whereas cough was predominantly dry in nature. Cardiovascular, central nervous systems and abdominal examinations were within normal limits. Based on these clinical findings, a provisional diagnosis of an acute pulmonary infection was made. Routine haematological and serological investigations were performed along with a chest radiograph.The chest radiograph demonstrated multifocal bilateral consolidation, along with cardiomegaly . EchocarCT-guided fine needle aspiration cytology and biopsy  of the lBecause of the severity of pneumonia and lack of response to the first line of antibiotic therapy, the patient required a short period of clinical stabilization on the intensive care unit. After successful treatment of the patient’s pneumonia, the patient was discharged. Because of comorbidity, the patient was deemed unsuitable for surgical resection of the pericardial fibroma, particularly given the fact that the patient remained asymptomatic at discharge. The patient will remain under regular clinical follow-up.4 Studies have shown that fibromas show heterogeneous contrast enhancement on post-contrast images, as also seen in our case.5 Morphologically, in our case, pericardial paraganglioma was a close differential diagnosis, especially the non-functioning type. Pericardial paragangliomas are also usually benign lesions and non-functioning, with functioning counterparts being very rare.Fibromas are rare primary pericardial mesenchymal tumours. Characteristically, they are benign tumours.5 Primary pericardial tumours present with non-specific signs and symptoms, with dyspnoea, chest pain, palpitations, fever and weight loss being the most common presenting symptoms. The patient’s clinical history is also very valuable in narrowing of differential diagnosis, for example, in a patient with known malignant neoplasm, pericardial lesion will most likely be a metastatic tumour. Primary pericardial lesions are classified as benign or malignant. The most common benign lesions are pericardial cysts and lipomas, whereas mesothelioma is the most common malignant primary pericardial tumour.2 While recognizing the key imaging appearances of primary pericardial tumours is important, histological evaluation is almost always required to confirm the diagnosis and guide further management.5Although chest radiographs and echocardiography are the most commonly utilized imaging tools to evaluate patients with suspected pericardial pathology, cross-sectional imaging is often required to diagnose pericardial tumours. While cardiac MRI is the cross-sectional imaging technique of choice in evaluating for suspected pericardial tumours, multidetector CT has also been shown to be reliable in the assessment of these patients and is particularly useful in institutions where cardiac MRI might not be as readily accessible.2 This, along with the avoidance of ionizing radiation exposure, makes cardiac MRI the cross-sectional imaging modality of choice when evaluating suspected pericardial lesions.CT scan and MRI both provide detailed assessment of the site of the pericardial tumour, tissue characteristics, extent of local invasion and relationship of the lesion to underlying structures that may contraindicate curative surgery.2 Pericardial fibromas have also been mentioned as presenting with palpitations, possibly because of their large size during presentation.Along with its usefulness in making a diagnosis, imaging also plays an important role in assessing the resectability of these lesions and evaluating the patient for associated complications. Some of the commonly seen complications include invasion of mediastinal structures, regional or distant metastases, pericardial effusion, cardiac tamponade, compression of vascular structures or cardiac chambers, encasement of vital structures, involvement of coronary arteries, myocardial infarction, diastolic dysfunction and constrictive physiology.Primary pericardial neoplasms are rare but are relevant tumours. Benign pericardial lesions may cause diagnostic dilemmas that are potentially resolvable by the appropriate use of cross-sectional imaging.In cases of malignant lesions, CT scan and MRI are of utmost importance in assessing the extent of invasion of these tumours and the extent of compression of cardiac chambers, pericardial effusion, constrictive physiology and locoregional or distant metastatic disease.


We present a case of an adrenal hemangioma, an uncommon cause of an adrenal mass, and review the clinical presentation, work-up, and management of adrenal incidentalomas.  A 64-year-old male was found to have a right adrenal incidentaloma during work-up for elevated liver transaminase levels, later found to be from hepatitis C. The mass was suspicious for adrenocortical carcinoma on CT imaging. Biochemical evaluation revealed no evidence of function. He underwent an open right adrenalectomy. The mass was found to be an adrenal hemangioma on histopathologic analysis.  This is a case report with pertinent review of the diagnosis and management of adrenal incidentalomas.  Adrenal hemangiomas are rare, benign, nonfunctional tumors typically found during imaging for other reasons. As illustrated by this case, they appear similar to adrenocortical carcinoma on CT imaging. The diagnosis is usually not made prior to surgical resection.  Adrenal hemangioma is a rare nonfunctional adrenal incidentaloma that displays atypical features on CT imaging. The suspicion for adrenocortical carcinoma usually prompts adrenalectomy. Adrenal hemangiomas are rare benign nonfunctional tumors typically found incidentally with imaging. Since the first reported case in 1955, there have been about 90 reported cases in the literature . PatientA 64-year-old white male with no prior medical history presented to his primary care physician for routine follow-up. There was no history of hypertension. During work-up for elevated liver transaminases, he was found to have hepatitis C. Before initiation of Harvoni, he underwent CT imaging of the abdomen with contrast which found a 5 × 6.7 × 7 cm right adrenal mass . On physOn CT imaging, the right adrenal mass contained scattered calcifications with small regions of fat. It enhanced in a peripheral globular fashion with central progression. The absolute contrast washout of 22.9% was indeterminate for adrenal adenoma . The masDue to the size and atypical features of the mass, right adrenalectomy was performed. An open thoracoabdominal approach was chosen due to the patient's low lying costal margin, the size of the mass, and retrocaval extension of the mass medially towards the vertebral body. The patient recovered well postoperatively and was discharged four days after surgery. The resected specimen weighed 126 grams and measured 7.5 × 6.5 × 4.7 cm on gross pathology . Within An adrenal incidentaloma is an adrenal mass that is generally 1 cm or more in diameter found incidentally during abdominal imaging done for other reasons , 5. In aIn a review of 2005 incidentally discovered adrenal masses, 82.5% were nonfunctioning benign lesions, 11.4% were functioning adenomas, and 7.2% were malignant lesions. Of nonfunctioning benign lesions, 61% were adenoma, 10% myelolipoma, 6% adrenal cyst, and 5.6% ganglioneuroma [The work-up of an adrenal incidentaloma includes, first, biochemical evaluation to determine if the mass is functional and, second, imaging to assess whether the mass appears malignant or benign. A careful history and physical examination may reveal specific signs and symptoms suggestive of a functional tumor. However, an asymptomatic patient should still be considered for biochemical testing, as 5% of tumors will demonstrate subclinical function. Of note, a pheochromocytoma must be excluded prior to any invasive procedure or surgery, since an untreated pheochromocytoma can lead to potentially lethal intraoperative hypertension..A limited work-up for function was felt sufficient by the endocrine service. An occult pheochromocytoma was excluded . The norIn addition to testing the mass for function, the mass must be evaluated for the possibility of malignancy. Metastatic disease is frequently bilateral to the adrenal glands, and usually the primary tumor has previously been identified . The twoThe mass in our patient had many of the imaging characteristics of adrenocortical carcinoma including size more than 4 cm, heterogeneous appearance, irregular enhancement pattern, delayed washout of contrast, and the presence of calcifications. Although calcifications are frequently present in adrenocortical carcinoma, calcifications are a nonspecific finding and may be seen in a variety of malignant and benign  adrenal lesions , includiOf benign adrenal masses, adrenal hemangiomas are rare. While there are limited data, adrenal hemangiomas have been found in a 2 : 1 female to male ratio, are usually unilateral, and have been found most often in the 6th and 7th decades of life [On histopathological evaluation, most adrenal hemangiomas are found in the adrenal cortex and consist of cavernous blood-filled sinusoidal channels that have eroded and displaced normal tissues . These dFunctional adrenal lesions, suspicious lesions, indeterminate lesions larger than 4 cm, or lesions that enlarge by 1 cm or more during observation should be considered for resection in medically fit patients , 4. If fThe surgical approach depends on the characteristics of the lesion. Most incidentalomas can be resected laparoscopically; however, an open surgical approach should be used if there is malignant potential or if the mass is large (greater than 6 to 10 cm) and appears difficult to remove .Adrenal hemangioma is an uncommon, benign, nonfunctional tumor that should be considered during the work-up of an adrenal incidentaloma. Due to the difficulty in distinguishing the lesion from an adrenocortical carcinoma on imaging and due to the small risk of spontaneous hemorrhage, surgical excision is usually recommended. The diagnosis is usually not made prior to surgery. Outcome after resection is excellent and recurrence should be uncommon.


Although cocooning of the abdomen is mostly seen in patients on peritoneal dialysis, it can occur A 46-year-old Asian man presented with complete mechanical bowel obstruction. He had previous attacks of partial bowel obstruction during the past 6 to 8 months, which was misdiagnosed as abdominal tuberculosis because tuberculosis is very prevalent in the region in which he lives. He took anti-tuberculosis therapy for 3 months but this did not result in resolution of his symptoms. This time he had diagnostic laparoscopy followed by laparotomy in which a fibrocollagenous membrane, resulting in entrapment of his bowel, was excised and his entire small bowel was freed.Postoperatively he again had a mild episode of partial bowel obstruction but this was relieved with a short course of steroids.Sclerosing peritonitis is a rare benign etiology of complete mechanical bowel obstruction. Patients might have suffered recurrent attacks of partial bowel obstruction in the past that were falsely managed on lines of other conditions such as tuberculosis, especially in endemic areas like Pakistan or India.Sclerosing peritonitis is a rare benign diagnosis which can manifest as complete bowel obstruction and a high index of suspicion is required to diagnose it. Contrast-enhanced computed tomography of the abdomen is a useful radiological tool to aid in preoperative diagnosis. Diagnostic laparoscopy is usually confirmatory.Peritoneal sac excision and adhesiolysis is the treatment and a short course of steroids in relapsing symptoms. Abdominal cocoon syndrome or sclerosing peritonitis is a rare condition that refers to total or partial encapsulation of the small bowel by a fibrocollagenous membrane resulting in partial or complete mechanical bowel obstruction . The conA 46-year-old Asian man presented with 5-day history of absolute constipation, vomiting, and central abdominal pain. Besides that he had no known comorbidities and an unremarkable family history. In the past he had similar complaints for which he was managed conservatively. At 4 months prior to his presentation he had a computed tomography (CT) scan of his abdomen for similar symptoms; the CT scan showed ileal thickening for which he was given empirically a 3-month course of anti-tuberculosis therapy (ATT) but his symptoms did not resolve.On this occasion, an examination revealed a dehydrated patient with pulse of 104 beats/minute and blood pressure (BP) of 130/70 mm. He had abdominal distention and central abdomen tenderness and hyperactive gut sounds. A digital rectal examination was unremarkable and so was a systemic examination. His baseline workup showed blood urea nitrogen of 32 mg/dl and creatinine of 1.2 mg/dl.Contrast-enhanced CT (CECT) of his abdomen showed mildly dilated thickened jejunal and ileal loops which were encased in a thick fibrocollagenous membrane pushed in the center of his abdominal cavity with collapsed loops of large bowel; the findings were suggestive of sclerosing encapsulating peritonitis/abdominal cocoon Fig.  a, b.FiHe was initially managed conservatively with intravenously administered fluids and nasogastric tube which resulted in some relief of his symptoms and his pulse of 74 beats/minute. Because of the fact that he came from an area where tuberculosis (TB) is a highly prevalent disease and previously he was empirically treated for abdominal TB, he underwent colonoscopy which showed normal terminal ileum, colon and rectum Fig.  a, b.FiHis case was discussed in a multidisciplinary team, which included a radiologist, gastroenterologist, and gastroenterology surgeon, and he was planned for diagnostic laparoscopy, followed by laparotomy in case it was not abdominal TB or a malignancy requiring medical management only.A diagnostic laparoscopy using 10 mm infraumbilical port in a vertical fashion, confirmed that entire small bowel was encapsulated in membrane and it was all plastered in the center of his abdomen. Hence, a decision was made for midline laparotomy, in which thickened sclerosing membrane encapsulating loops of small bowel was removed and whole small bowel was freed and run until ileocecal junction. His stomach appeared thickened while his colon appeared grossly unremarkable Fig.  a, b.FiPostoperatively he remained well and was discharged on fourth postoperative day, when he was tolerating an oral soft diet. However, he was again admitted on third day after his discharge with complaints of vomiting and relative constipation. He was kept nil by mouth (NPO) and on parenteral nutrition. Along with conservative management he had a short course of hydrocortisone 50 mg thrice daily for 7 days, which was tapered off later; he responded very well and he was discharged in a stable condition on oral soft diet with normal bowel movements.He was followed up in clinic after 10 days and he was tolerating a soft diet with normal bowel movements; his stitches were removed in clinic. Later, a histopathology report showed fibrocollagenous tissue with mild chronic inflammation and mild patchy increase in IgG4-positive plasma cells.He was seen twice as an out-patient at 3-month intervals and appeared asymptomatic; he was advised to have further follow-up only if required.Sclerosing encapsulating peritonitis was first described more than a century ago and was initially termed peritonitis chronica fibrosa incapsulata to describe the membrane encasing the intestine; it has since also been named ‘icing sugar’, fibroplastic peritonitis, and cocoon abdomen. Sclerosing encapsulating peritonitis has been classified as primary and secondary based on whether it is idiopathic or has a definite cause.The etiology of the primary form is uncertain with various hypothesis, although it is probably caused by a subclinical peritonitis leading to the formation of a cocoon –5. CytokSecondary sclerosing peritonitis, which is more common, has many causes. The predominant cause of sclerosing peritonitis is PD. Patients on PD are predisposed to developing peritoneal deterioration after prolonged exposure to PD fluids and subsequent bacterial peritonitis , 8. OtheThe results of baseline investigations are often similar to those found in small bowel obstruction, such as dehydration and decrease in oral intake, and there may be electrolytes imbalance and acute kidney injury with raised creatinine. Abdominal X-ray findings are non-specific. CECT is a useful tool for preoperative diagnosis of abdominal cocoon , 10. TheDiagnostic laparoscopy is generally confirmatory and rules out other causes , 12; howTreatment, as in this case, is excision of membrane and releasing loops of bowel , 13. BowSclerosing peritonitis is one of the rare causes of complete mechanical bowel obstruction and it should be in the differential diagnosis when no other obvious cause of bowel obstruction is found. Surgical exploration in which dense sclerosing membrane over the bowel is removed and bowel is straightened is the treatment of choice up until now. A short course of steroids is also helpful in the postoperative period.


Giant ovarian cysts are rarely described in the literature, owing to the availability of advanced imaging technologies in developed countries leading to early treatment. In resource-limited settings, various factors lead to late presentation.We present a case of a 48-year-old black African woman with a giant mucinous cystadenoma who presented to a tertiary hospital with massive abdominal distention 5 years after being referred from a district hospital for the same problem. Surgical management resulted in fatal complications.The surgical management of these huge tumors is associated with many life-threatening complications. Transvaginal ultrasound should be used in resource-limited settings to delineate ovarian masses. Community health workers must be involved in scouting and follow up of community members with unusual abdominal swellings in developing countries to avoid delays in care. Tumors of the ovary presenting with diameters greater than 10 cm are referred to as giant ovarian cysts .These tumors are generally asymptomatic at early stages, causing symptoms only after reaching enormous dimensions, and consequently are diagnosed late in low- and middle-income countries (LMICs) . CompresThe surgical management of these masses is associated with many life-threatening complications, which arise predominantly after surgery owing to rapid changes in body circulation, and with pulmonary edema. The former include severe hypotension, increased venous return, cardiac failure, respiratory failure, and intestinal distention .We report a case of a 48-year-old woman with a giant mucinous cystadenoma who presented with massive abdominal distention and whose surgical management resulted in fatal complications. We aim to remind clinicians of the challenges in diagnosing, managing, and precautions to be taken when performing surgery for patients with giant ovarian cysts.A 48-year-old, para 5, postmenopausal black African woman who was human immunodeficiency virus (HIV)-negative presented to our casualty department with a 5-year history of progressive abdominal swelling. Five years prior to presenting, which was 1 year before she reached menopause, she had noticed that her abdomen was gradually distending. Her symptoms were associated with constipation, feeling of incomplete rectal emptying, early satiety, vomiting, and urinary frequency and urgency. She did not have any chronic illnesses and had a negative personal and family history of ovarian, uterine, bowel, and breast cancers. She was not receiving any medication prior to this presentation. She had delivered five children by cesarean section, and they were all alive and well. She lived in a rural area and was a subsistence farmer. She did not smoke and did not drink alcohol.She had ascitic taps three times in 1 week at a district hospital before referral to a higher-level hospital because of recurrent reaccumulation of ascites. A transabdominal ultrasound scan (USS) showed generalized ascites with a thick fluid with septa, as well as bilateral mild hydroureter and hydronephrosis. Again, the ascites was drained twice. One month later, she underwent computed tomography (CT), which showed a large predominantly cystic lesion that occupied almost the entire abdominal and pelvic cavities, which were distended, causing a marked mass effect on surrounding organs and bowel. The lesion had areas of internal septation predominantly on the right flank with no features of metastatic disease. Tumor markers measured during this admission are shown in Table The patient was referred to a tertiary hospital but only went 5 years later. Upon admission, she had marked temporal wasting, with bilateral pitting lower limb edema extending to her sacrum. She had a normal breast examination. Her blood pressure was elevated at 167/93 mmHg, with tachycardia of 150 beats/min. Her body temperature was 36.8 °C. She had equal air entry bilaterally, and her cardiorespiratory and neurological systems were normal. She had a lower midline scar with massive abdominal distention that was nontender and had a positive fluid thrill test result  that included gynecological oncologists, radiation oncologists, general surgeons, anesthetists, and nursing staff. The MDT considered the risks of death following hemodynamic instability and bleeding as well as the postoperative risks of deep vein thrombosis, pulmonary embolism, difficulty weaning off the ventilator, and death. The conclusion of the meeting was to take the patient for staging laparotomy despite these risks.Preoperatively, the patient and her relatives were counseled on the possible complications. The patient received a transfusion with 2 Units (U) of packed cells (PCs). The team also contemplated drainage of the mass preoperatively but was unable to secure appropriate drains to drain the thick green fluid from the mass.At laparotomy, through a right paramedian incision, a huge abdominopelvic mass was found filling the whole abdomen and pelvis. The liver, spleen, and hemidiaphragms looked normal. The mass was shelled out by blunt dissection Fig. . The masThe patient was critically ill in the ICU. On the day of admission, she had a cardiac arrest and was successfully resuscitated. She required inotropic support and ventilation. By day 5, she had developed hepatosplenomegaly, uremia, and an increased international normalized ratio. She was leaking serous fluid from the suture line, with darkening of the previously stretched skin of the anterior abdominal wall. She remained anemic with thrombocytopenia. She received a further 6 U of PCs. She was kept on albumin and given high-protein energy feeds by the dietitian in view of her hypoalbuminemia and malnutrition. By day 6, she was noted to have disseminated intravascular coagulopathy. She was given vitamin K. A pneumothorax was noted, and the cardiothoracic surgeon inserted a chest drain. She was also noted to have aspiration pneumonia following a self-extubation on the same day. By day 10, she was noted to have multiple organ failure with oliguria, falling level of consciousness, aspiration pneumonia, a gangrenous abdominal wall Fig. , and coaShe required inotropic support and ventilation. She died on day 10 after surgery. The pathology report showed a partial cystic lesion with benign epithelia of mucin-secreting columnar cells, no evidence of stromal invasion, no stratification, and no atypia and intraluminal mucin Fig. . The cysWe report a case of a 48-year-old woman with a giant mucinous cystadenoma who presented with massive abdominal distention and whose surgical management resulted in fatal complications. Benign mucinous cystadenomas make up the majority (81%) of mucinous tumors. These tumors can grow to extremely large sizes and are among the largest of any recorded tumor in the body , as was This patient presented to the tertiary hospital 5 years after being referred from the district hospital. In low-resource settings, late presentation is a common feature due to socioeconomic factors as well as cultural beliefs and fear of surgery leading most to present when the symptoms become unbearable . It is tAmong the tumor markers measured in our patient, lactate dehydrogenase (LDH), carcinoembryonic antigen (CEA), and cancer antigen 125 (CA 125) were elevated. At the time the tests were done, the patient was 43 years old and premenopausal. The CA 125 assay is unreliable in differentiating benign from malignant ovarian masses in premenopausal women because of the increased rate of false-positive results and reduced specificity . When CAOur patient’s case displays the shortfalls of transabdominal USS as an imaging modality for the assessment of suspected ovarian masses. Although a pelvic ultrasound is the single most effective way of evaluating an ovarian mass, transvaginal ultrasonography is preferable because of its increased sensitivity over transabdominal ultrasound. A transabdominal USS should not be used in isolation; it should be used to provide supplementary information to transvaginal ultrasound, particularly when the ovarian cyst is large . Our patAs in our patient’s case, most mucinous tumors (about 79%) are unilateral. An algorithm was proposed in which a tumor greater than 10 cm correctly predicted primary ovarian origin in 82% of cases .Our team considered aspiration of the tumor prior to surgery. However, some authors state that aspiration of abdominal cysts should be avoided because this could cause complications such as infections, bleeding, cyst rupture, increased peritoneal adhesions, or possible dissemination of malignant cells. They therefore consider preoperative and intraoperative drainage unsafe . In the The gold standard of treatment of any suspected ovarian mass includes intact removal of the involved adnexa with intraoperative pathological evaluation, typically laparotomy, total hysterectomy, bilateral salpingo-oophorectomy, and staging procedure, including lymphadenectomy . SurgeryAdequate supportive care while resecting giant ovarian masses is of the utmost importance. Postoperatively, reducing ileus, providing respiratory support, supporting abdominal wall tension, and monitoring hemodynamic parameters are key . After tWhen the abdomen is entered surgically, care should be taken to remove the ovary intact without spillage of the cyst contents, because rupture of a stage I mucinous ovarian carcinoma may increase its potential for recurrence. Benign mucinous cystadenomas are by definition confined to the ovary, and no further procedure is required. Therefore, had a frozen section been available, this diagnosis would possibly have enabled an oophorectomy to be performed, and the hysterectomy that contributed to additional theater time could have been avoided. Consideration also needs to be given to the fact that though benign, borderline to invasive disease may exist as a continuum in a cystadenoma. Only a limited number of sections can be evaluated intraoperatively because these tumors are quite large; hence, this may contribute to inaccuracies in diagnosis with frozen sections. Although appendectomy was previously performed for any ovarian tumor with mucinous histology, including benign lesions, current data do not support the practice .The mass was not weighed, because it ruptured and was drained intraoperatively. A review of 20 cases with lesions exceeding 20 kg confirmed a low malignancy rate .Benign mucinous cystadenomas can grow to massive sizes, particularly in LMICs, and provide a huge surgical management challenge. Transvaginal ultrasound should be employed early to clearly delineate the ovaries, particularly in resource-limited nations. Community health workers in developing countries must be involved in scouting and follow-up of community members with unusual abdominal swellings to avoid delays in care.


The authors present a case of tension pneumocephalus that occurred secondary to closed head injury and review the etiology and management of this relatively rare entity. This case was managed without invasive neurosurgical intervention, also somewhat rare for this condition. Pneumocephalus is a collection of air or gas within the intracranial cavity and is a common finding following traumatic skull fractures and neurosurgical procedures . TensionWe report the case of a 62-year-old male with a history of alcoholism who presented to the emergency department by ambulance, complaining of a frontal headache after a ground-level fall from standing with associated head trauma. His family reported that the patient had been weak and dizzy in the preceding four days with recurrent falls. However, this particular event resulted in the patient being briefly unresponsive, which prompted them to call 911 . Physical examination was notable for a right supraorbital laceration. Neurological examination revealed intact cranial nerves and no focal motor or sensory deficits. He was afebrile, with normal blood pressure, pulse, and respiration. His Glasgow coma scale (GCS) score was 14/15 (E4 V4 M6).The noncontrast head CT revealed no acute fractures but showed subdural air with separation of the frontal lobes by subdural air-findings concerning for tension pneumocephalus Figure . NeurosuThere are several mechanisms by which pneumocephalus develops. With a skull fracture or neurosurgical procedure, direct inoculation of the intracranial space with air is expected. Dural injuries can lead to tension pneumocephalus when air enters through the defect while a plug of brain parenchyma or dural membrane prevents that same air from exiting, creating a ball-valve effect -5. AnothConservative treatment of tension pneumocephalus involves semi-recumbent positioning with head-of-bed elevation to 30-45 degrees, avoidance of Valsalva maneuvers, pain control, prevention of hyperthermia, and osmotic diuretics . With coWhat we learned from this case is that tension pneumocephalus is a relatively rare neurosurgical emergency that can sometimes be managed conservatively. The presenting symptoms can be nonspecific, as with our patient. Thus, maintaining a high index of suspicion for this pathology is very important. Once suspected, the diagnosis is made relatively easily on noncontrast CT.


Xanthogranulomatous pyelonephritis is a rare form of chronic pyelonephritis that generally afflicts middle-aged women with a history of recurrent urinary tract infections. Its pathogenesis generally involves calculus obstructive uropathy and its histopathology is characterized by replacement of the renal parenchyma with lipid filled macrophages. This often manifests as an enlarged, nonfunctioning kidney that may be complicated by abscess or fistula. This case details the first reported case of xanthogranulomatous pyelonephritis complicated by urinothorax, which resolved on follow-up chest X-ray after robot-assisted nephrectomy. Xanthogranulomatous pyelonephritis (XGP) is an uncommon but distinct form of chronic infective pyelonephritis that typically presents in a woman in her fifth or sixth decade of life with abdominal pain, fever, palpable mass, anorexia, weight loss, hematuria, dysuria, and a persistent urinary tract infection that is resistant to antimicrobial therapy. Diagnosis of XGP is initially made radiographically with histopathological confirmation. Histopathologically, XGP is characterized by replacement of renal parenchyma with granulomatous tissue composed of lipid-laden macrophages , 2. TreaA 36-year-old woman with a history of obesity, hypertension, anxiety, and recurrent urinary tract infections (UTI) was admitted to the hospital with history of dyspnea, fever, cough, and abdominal pain for 4 days.Prior to this admission, the patient presented to urology with recurrent UTIs and was determined to have a left staghorn renal calculus. Recommendations were for the patient to undergo surgical removal of the stone; however the patient refused due to risk of complications associated with her obesity. Up until this admission, the patient had experienced numerous UTIs, most with multidrug resistant bacteria, and had undergone multiple courses of antibiotics.3 per μL. Comprehensive metabolic panel was significant for creatinine 0.76 mg/dL, lactate dehydrogenase 249 IU/L, albumin 3.3 g/dL, and total protein 6.7 g/dL. Chest X-ray (CXR) showed a large left sided pleural effusion with no consolidation , making it the first reported case of urinothorax (UT) secondary to XGP.A rare and unusual cause of pleural effusion, UT, describes the phenomenon of urine in the pleural space. Initially described by Corriere et al. in their 1968 study of ureteral obstruction in dogs, UT in human patients has been described as a rare complication of bilateral urinary obstruction or trauma to the urinary tract . The diaUT can be classified as either obstructive or traumatic. The former manifests from a bilateral obstructive uropathy and the latter is most commonly due to iatrogenic injury of the urinary tract . The patFirst described by Schlagenhaufer in 1916, XGP is a rare but serious type of chronic kidney inflammation that can be life-threatening if not treated appropriately . Cases g Escherichia coli UTIs that lead to development of XGP with subsequent development of urinothorax. Diagnosis was made through chemical analysis of the pleural fluid in addition to imaging. The UT resolved after nephrectomy.Management of UT requires correction of any underlying potential urinary tract pathology to prevent recurrence and persistence. Currently, no guidelines exist for optimal treatment of XGP but, generally, treatment consists of a combination of broad spectrum antibiotics and nephrectomy , 17. In Urinothorax is a rare diagnosis that is easily overlooked without a high degree of clinical suspicion. This case of urinothorax secondary to xanthogranulomatous pyelonephritis suggests that urinothorax should be included in the differential diagnosis of patients presenting with pleural effusion and recent urinary tract pathologies or nephrolithiasis.


Pyogenic liver abscess, having experienced an evolving pathogenesis over the years, still remains a serious problem with significant morbidity. Iatrogenic and ascending biliary infections are the most common known etiologies for hepatic abscess. Here we report an interesting case of an elderly lady admitted with abdominal pain due to a pyogenic liver abscess in the left liver lobe which was attributed to perforation by an ingested fish bone. The authors also reviewed literature for management for this rare case as there are no standard guidelines. Our patient was successfully treated with antibiotics and percutaneous drainage with foreign body left in situ. Pyogenic liver abscess is becoming a rare cause of abdominal pain with very low estimated annual incidence at 2.3 cases per 100,000 people [9 cells per liter, total bilirubin 2.4 mg/dL, alkaline phosphatase 114 units per liter (U/L), AST 62 U/L, ALT 59 U/L, and albumin 2.6 g/dL. An abdominal computed tomographic (CT) scan was performed and showed a 6.9 cm heterogeneously enhancing abscess collection within the left hepatic lobe , percutaneous drainage (PCD), or surgical drainage. Percutaneous drainage has gained favor recently as an effective method that is cost effective, carrying lower mortality. In a large study by Mangukiya et al., 56% of diagnosed patients with hepatic abscess were treated with aspiration, while abscess of 10 cm or greater underwent percutaneous drainage therapy with excellent results , 8. Our In conclusion, we believe percutaneous drainage is the appropriate first line treatment in most cases, even in cases of retained of foreign body. Surgical retrieval portends the risk of additional injury to organs, inflammation, and source for sepsis. Our case demonstrates that when the clinical condition of the patient is stable and improving with percutaneous drainage and antibiotics, it may be prudent defer surgical operation.


Acute pancreatitis is associated with a number of well-known complications and imaging findings. Spontaneous recanalization of the paraumbilical veins as a consequence of pancreatitis in a patient with an otherwise normal liver is, however, a rare entity. This case report depicts this unusual complication as a consequence of gallstone pancreatitis in a patient with a non-cirrhotic liver and no clinical or radiological evidence of portal hypertension. There was recanalization of the paraumbilical veins followed by thrombosis, which is believed to have propagated in a retrograde fashion into distal branches of the otherwise patent portal vein. A literature search for similar cases such as this has yielded no results. Although rare, clinicians and radiologists alike need to be aware of this finding. This case discussion highlights the embryology and anatomy of the paraumbilical veins, as well as discusses the management of paraumbilical and portal vein thrombosis. Acute pancreatitis has a number of well-recognized complications; however, recanalization of the paraumbilical vein is less well recognized and carries its own imaging findings and associated abnormalities. Although rare, clinicians and radiologists alike need to be aware of this finding.A previously well 52-year-old male presented to the hospital with a 5-day history of abdominal tenderness, which was maximal in the left iliac fossa.An abdominal film performed in casualty was non-specific, while inflammatory markers were raised. Liver enzymes demonstrated a mild transaminitis and a normal amylase. The patient proceeded to get a CT scan that demonstrated a swollen, oedematous pancreas with peripancreatic inflammatory change . The gla−1—normal reference range 0–100 U l−1). With a working diagnosis of obstructive ductal stones, a repeat MRCP was performed, showing a 12-mm calculus impacted at the ampulla  contrast-enhanced CT scan of the liver was performed. The newly recanalized and partially thrombosed paraumbilical vein was shown to have a maximal cross-sectional diameter of 3.8 cm . DespiteThe patient subsequently underwent endoscopic retrograde cholangiopancreatography, where the common bile ducts were noted to be moderately dilated. No ductal filling defect was present. Sphincterotomy and balloon sweep retrieved some stone debris.The patient was anticoagulated and after discussion with haematology, 6 months of warfarin therapy was planned. Ultimately, it was planned that cholecystectomy would be the best course of definitive action.Although portal vein thrombosis is well recognized following acute pancreatitis, acute recanalization of the paraumbilical vein is rare. The relatively small volume of portal vein thrombosis in this case is even more unusual, and demonstrates the need for clinicians and radiologists alike to be aware of uncommon complications of acute pancreatitis.In utero, within the umbilical cord, a single or unpaired umbilical vein provides the foetus with oxygenated blood from the placenta. At the caudal rim of the navel, the unpaired umbilical cord connects with an intrafoetal left and right umbilical vein, which drain into the omphalomesenteric veins. The left and right umbilical veins are incorporated into the developing liver, establishing a connection with the capillary plexus. Consequently, there is communication with the sinus venosus, both directly and via hepatic anastomoses.1 The portal vein arises from segments of the vitelline veins, with the portal sinus derived from subhepatic intervitelline anastomosis connecting the umbilical vein—the predominant vessel of the foetal liver—to the portal system. The ductus venosus connects the portal sinus to the vena cava.2 With atrophy of the extrahepatic portion of the umbilical veins, blood from the umbilical cord reaches the sinus venosus and gets mixed with blood from the omphalomesenteric veins that pass through the liver.1Subsequently, there is atrophy of the right umbilical vein with the placental blood entering the liver via the left umbilical vein, which, following birth, is obliterated and the ductus venosus becomes the ligamentum venosum.3 with correlation to post-mortem findings revealed no cases in which there was recanalization of the umbilical vein but instead showed an increase in the calibre and number of paraumbilical veins in patients with portal hypertension.Contrary to popular belief, the umbilical vein itself generally does not recanalize with portal hypertension. A study of patients with portal hypertension performed by Lafortune et alRecanalization of the paraumbilical veins is mainly secondary to portal hypertension, which is defined as elevation of hepatic venous pressure gradient of >5 mmHg. Portal hypertension is a consequence of increased hepatic vascular resistance that can broadly be classified as prehepatic, intrahepatic or posthepatic.The prehepatic causes in an adult population are almost all as a result of portal vein thrombosis. Intrahepatic portal venous hypertension can be the result of cirrhosis, fibrosis and, less commonly, in non-cirrhotic patients owing to hepatosteatosis, schistosomiasis, tuberculosis etc. Posthepatic portal hypertension generally results from thrombosis of either the hepatic vein or inferior vena cava.By far, the most common causes of portal venous hypertension are increased intrahepatic vascular resistance as a result of hepatic cirrhosis and a consequence of portal vein thrombosis.The cause of portal vein thrombosis is often multifactorial but can be broadly classified into either local causes or systemic prothrombotic states. The presentation and clinical symptoms depend largely upon the speed of onset of thrombosis, ranging from acute infarction with subsequent haemorrhage in the acute setting to the sequelae of portal hypertension with variceal bleeding and cavernous transformation with multiple bridging collaterals bypassing the occlusion.6Malignancy, in particular hepatocellular carcinoma (HCC), is an important local cause of portal vein thrombosis with pathological studies showing this tumour subtype having a greater propensity for venous invasion than do other primary hepatic tumours or metastatic deposits.Other local causes include trauma, surgery, intra-abdominal sepsis, splenectomy and regional inflammatory processes, such as pancreatitis.7Spontaneous recanalization with blood flow in the umbilical vein may occur during portal hypertension with the spontaneously reopened umbilical vein serving as a hepatofugal, decompressing collateral.The peculiarity of this case presentation lies in the fact that, between clinical presentations, there has been spontaneous recanalization of the paraumbilical veins and subsequently thrombosis in a patient with a non-cirrhotic liver and a largely patent portal venous system. A small volume of thrombus was noted within distal portal branches supplying the left lobe of the liver, which was most likely the precipitating cause. The remainder of the portal vein was patent.The imaging findings in portal venous and paraumbilical vein thrombosis does vary depending on the chronicity of the clot.On ultrasound, an acute thrombus typically appears either anechoic or hypoechoic and therefore is difficult to detect. With time and clot maturation, the thrombus becomes hyperechoic. Colour Doppler is useful in determining whether or not there is flow within the portal vein; however, in cases where flow is sluggish, discernible Doppler flow may be absent, giving false-positive results.8CT scan appearance of thrombus again varies with the age of the clot. On unenhanced studies, an acute clot can appear relatively hyperdense relative to the adjacent liver parenchyma, becoming iso-hypodense over time. With the administration of iodinated contrast, a clot appears as a filling defect, either partial or complete.Because the liver has a dual blood supply from both the hepatic artery and the portal vein, physiological changes can affect the enhancement pattern. One such phenomenon is known as THAD on CT or transient hepatic intensity difference on MRI, which equates to relative hyperenhancement of a liver territory during the hepatic arterial phase. There are a number of different causes that include lesions, such as HCC, and other non-lesional causes, such as portal venous thrombus. The mechanism is thought to be secondary to a relative mismatch in flow between the hepatic artery and the portal venous supply, with a relative increase from the hepatic artery.T1 weighted and T2 weighted sequences. With increasing chronicity, there is loss of T2 weighted signal. MR angiography with the administration of gadolinium, similar to CT, is able to demonstrate filling defects as a result of clot. Tumour thrombus generally enhances, is typically hyperintense on T2 weighted sequences and is an important differential for portal vein thrombosis.11MRI has been stated to be the most sensitive imaging modality for the detection of portal vein thrombosis with a sensitivity of 98% and a specificity of 99%; however, it does have limitations to its use, especially in acutely unwell patients. Portal venous thrombus has a varied appearance on MRI, which again is related to age of the thrombus and the specific MRI sequence. Classically, in the acute setting, a clot will appear as a high signal intensity on both The second admission with obstructing distal stones was the cause of the patient’s abnormal liver enzyme tests. It is difficult to definitively determine whether it was the distal ductal stone or the acute thrombosis of para-umbilical veins that was the cause of the patient's abdominal pain or possibly a combination of both. Recanalization of the umbilical vein in the absence of cirrhosis and significant portal vein thrombosis is extremely rare, and this case serves as a reminder for the less common causes of right upper quadrant pain and complication of acute pancreatitis.Recanalization of the paraumbilical vein is an important but rare consequence of acute pancreatitis.Portal vein thrombosis usually accompanies this finding, and as this case demonstrates, thrombus load can vary.The reporting radiologists need to be vigilant to such complications at imaging, particularly as studies, such as MRCP, are optimized to detect portal vein thrombosis or paraumbilical vein recanalization.


Conjunctival papilloma is an acquired benign squamous cell tumor that can present at any age, but most frequently in the third and fourth decades of life. Papillomas have been associated with human papilloma virus (HPV) infection, usually types 6 and 11.Although histopathological diagnosis remains the gold standard, the advent of newer non-invasive imaging modalities such as optical coherence tomography (OCT) is transforming the way we diagnose and treat ocular surface tumors, including conjunctival papilloma. Management of these lesions can prove a challenge to the treating physician since not all lesions respond to medical and/or surgical therapy and in fact may worsen after surgical manipulation.In this review, the epidemiology, pathophysiology, clinical characteristics, and diagnosis of conjunctival papilloma including the use of OCT are discussed. Indications, efficacy, and side effects of currently available management options are also reviewed to guide the selection of the best treatment approach. The first reported case of conjunctival papilloma dates back to 1883, when Critchett and Juler described a small reddish mass near the inner canthus of a 14-year-old girl presenting with discomfort and slow increase in size for 5 years . L. L55]. LIn terms of location, some groups have identified the caruncle as the most commonly affected site in adults (24 to 43% of lesions) , 48, whiThe exophytic pattern can be sessile or pedunculated, and is usually covered by multi-layered, non-keratinized squamous epithelial cells and a varying number of goblet and acute inflammatory cells . ExophytInverted or endophytic papillomas are made of invaginated lobules of proliferating, non-keratinized squamous epithelial cells which contain goblet cells and grow towards the substantia propria of the conjunctiva . The invIn one study, histological differences were noted by HPV status. HPV-positive papillomas were mainly composed of basaloid cells with intraepithelial goblet cells, had extra-limbal location, and did not exhibit elastosis . On the Benign papillomas may occasionally contain areas of dysplasia which are characterized by the presence of cytologic atypia, epithelial thickening, lack of goblet cells, and mitotic figures extending beyond the basal layer . On examMultiple conditions can resemble conjunctival papillomas to some degree, including benign lesions of the surface epithelium , vascular lesions , malignant lesions , secondary tumors, and other ocular diseases  .Patients should be asked about history of ocular surgery and trauma, malignancy, immunodeficiency, presence of genital warts and risk factors for sexually transmitted diseases, genital HPV, vaccination status, immunosuppression, and UV light exposure. In pediatric patients, maternal HPV exposure should be elicited.Clinical examination aids in tumor categorization and should include eyelid eversion. Lesion characteristics such as basal dimension and thickness, configuration , intrinsic vascularity, feeder vessels, presence of pigment, and tumor location should be noted . BaselinTumor palpation is performed during the slit lamp examination using a cotton-tip applicator under topical anesthesia. Most papillomas should be freely mobile over the sclera with the body of the papilloma forming a mushroom shape over a pedicle attached to the conjunctiva. On the other hand, an epithelial lesion that has invaded the underlying connective tissue will feel fastened to the globe  and shouBiopsy for conjunctival papilloma is controversial. On one hand, histopathological analysis showing the previously described characteristics is the gold standard for diagnosis. On the other hand, there is concern that cutting in the area of the lesion can disseminate the virus and lead to new lesions , 49. As Impression cytology, a long-standing diagnostic technique first described for conjunctival use in the ‘70s , is the Impression cytology has yielded positive results in 77 to 97% of biopsy-proven OSSN –71. HoweAs anterior segment imaging evolved with improved image quality, easier operation, and expanded applications, non-invasive imaging diagnosis and surveillance have become a reality and increasingly valuable in the management of ocular surface tumors. While no imaging technique is perfect, these tools can aid in the diagnosis and management of conditions such as OSSN, precluding the need for excisional or incisional biopsies .Rapid, non-contact OCT image acquisition does not require a highly skilled operator, and images can be interpreted by experienced as well as novice clinicians . The disTherapeutically, HR-OCT helps confirm tumor regression by allowing for direct tumor measurement on the scans and comparison of serial pictures. After successful medical therapy or surgical intervention, HR-OCT findings can confirm the normalization of the epithelium Fig. a-d. By dThe limitations of HR-OCT include optical shadowing of deeper structures that can occur with large papillomas. In addition, lesions in the fornix and/or caruncle can be difficult to image , 75. WhiUBM is able to penetrate opaque ocular surface lesions, assess presence of invasion, and visualize the posterior border of the tumor at the expense of axial resolution (20 to 50 μm) . As oppoUBM has proven to be helpful in assessing tumor depth and invasion in other ocular surface tumors –79, but In the early twentieth century, wide surgical excision of conjunctival papilloma with cauterization of residual conjunctiva was historically recommended as the best treatment approach . AlthougOnce the diagnosis and extent of the conjunctival papilloma have been established, there are many factors to consider before deciding on the best treatment modality. The choice of therapy for each individual patient depends on age, systemic comorbidities, location, extension and aggressiveness of the papilloma, ability to comply with medications and/or undergo surgery, and financial constraints.Considering that slow spontaneous regression can occur in a number of cases, observation and reassurance are reasonable and in fact indicated for small asymptomatic conjunctival lesions , 83. RecA trial of topical steroids can be considered when an inflammatory process  is suspected. However, clinical examination and ancillary imaging can typically differentiate the two entities. Conjunctival papilloma generally does not show tumor regression with corticosteroids.Serial slit lamp photographs should be obtained to monitor for growth or changes in patients, with a frequency of examination between 3 to 6 months depending on the level of concern and progression .Interferon (IFN) is an endogenous immunomodulatory glycoprotein released by various immune cells with antiviral, antimicrobial and antineoplastic functions . Its ant2 (MIU/m2) were administrated daily for 1 month and then 2 or 3 times weekly for another 5 months. Although initially suppressive, recurrence was seen in 3 out of 5 patients upon IFN taper or discontinuation. de Keizer reported using systemic IFN administered subcutaneously 3 times weekly (5 × 106 U) for 6 months for conjunctival papilloma, leading to the shrinkage but not resolution of recurrent conjunctival papillomas in a 38-year old woman ..49]. DurAfter tumor removal, either conjunctival undermining and primary closure, autograft from the fellow eye, amniotic membrane or even buccal mucosa transplantation can be used for conjunctival defect coverage , 128. A We consider surgery in individuals with large or pedunculated lesions that are symptomatic and in children where amblyopia is a concern . UltimatMMC has also been administered intraoperatively as an adjuvant agent after surgical excision. Its use intraoperatively for the treatment of conjunctival papilloma was first reported in 1996 . A 5-yeaSince then, studies have found intraoperative MMC to be effective even in very extensive lesions , 132. SuMMC is applied at concentrations of 0.2 or 0.3 mg/ml via a cellulose sponge, which is held in the area of excision for 2 to 3 min followed by copious irrigation with normal saline , 82, 132Topical and/or intraoperative adjuvant immuno- and chemo-therapeutic agents such as IFN α-2b or MMC are administrated in addition to excision in an attempt to reduce the risk of recurrences, especially in resistant and aggressive papillomas. As above, if surgery is needed, our recommended surgical approach consists of a combination of a ‘no-touch’ surgical technique with adjunctive double freeze-thaw cryotherapy and intralesional IFN α-2b (3 MIU/0.5 ml) at the time of surgery. However, there are no randomized control trials comparing the effectiveness of surgical resection with and without adjuvant therapies, and treatment recommendations are mostly based on small or anecdotal reports. A recent publication showed that excisional biopsy, cryotherapy, intralesional IFN and post-operative topical IFN for 3 months was successful in eradicating recurrent, multifocal papillomas in a 2-year old child who did not respond to primary topical IFN drops . No recuDinitrochlorobenzene (DNCB) is a chemical first identified in the study of glutathione-S-transferases and found to cause a type IV hypersensitivity reaction . Its proDNCB immunotherapy has been used for the treatment of conjunctival papilloma with mixed results. In 1981, DNCB immunotherapy  was first reported to be successful in a 24-year old man who suffered from a benign papilloma recurrent with atypia and resistant to electrocautery, surgical excision and cryosurgery . The patBevacizumab is a humanized monoclonal antibody against vascular endothelial growth factor (VEGF) activity that inhibits angiogenesis .Its use as an adjuvant off-label therapy for recurrent conjunctival papilloma has recently been reported . A 29-yeIn terms of side effects, the study above reported none. In addition, no local or systemic side effects were encountered with the use of anti-VEGF agents for the treatment of OSSN , 144. Ho2 laser that generates temperatures of around 750 degrees Fahrenheit. The thermal damage not only precisely disrupts the surrounding 100 μm of tissue but is also thought to decrease the chances of viral seeding by inactivating HPV and sealing the lymphatic vessels [First used by otolaryngologists for tracheal and laryngeal papillomas, this approach consists of the use of infrared CO vessels , 146. Th vessels .2 laser therapy was used in the 1980s concurrently with surgical excision for treatment of highly aggressive and recurrent conjunctival papillomas not responding to prior rounds of surgical excision, cryotherapy, chemotherapy, and immunotherapy [2 laser and followed up for over 2 years, 2 recurrences were observed. Comparatively, the reported recurrence frequency with surgical excision alone was 20% [The COotherapy –148. In  was 20% .During the medical treatment period, patients should be followed every 1 to 2 months to assess treatment response and identify possible adverse events. Patients treated surgically are usually seen 1 day, 1 week, 1 month, and every couple of months after surgery. Upon resolution, follow-up every 3 months during the first year, every 6 months during the second year, and yearly thereafter is generally indicated to rule out recurrence.2 laser or MMC)  [Recurrence frequencies after all treatments range from 3 to 27% , 48. TheOther factors associated with higher recurrence include bulbar conjunctival location and corneal involvement . No assoFor OSSN, it has been shown that the presence of microscopic disease at the lesion border may increase the risk of recurrence , 151. ThConjunctival papilloma is a benign epithelial tumor of the conjunctiva that can occur at any age in pediatric and adult patients. HR-OCT is a non-invasive diagnostic tool that can help identify lesions without the need for biopsy and assess treatment response. Papillomas can be managed medically, surgically, or with a combined approach depending on patient and tumor factors. Observation is also an option for small and asymptomatic tumors. Medical management is generally preferred given the theoretical lower risk of viral seeding. When used before surgery, medical therapy can debulk the lesion and minimize tissue excision. For papillomas that require surgical excision, a ‘no-touch’ technique along with cryotherapy and intraoperative MMC or IFN injection should be considered to reduce the risk of recurrences. Close surveillance is necessary to ensure timely detection and treatment of recurrences.Despite the benign nature of the tumor, treatment can be challenging with the occurrence of medical treatment failures and recurrences after medical and surgical interventions. There is a paucity of published data with the use of topical chemotherapies as primary interventions, and overall from our experience as well as from the literature review, it seems that lesions with a higher degree of dysplasia tend to respond better to topical chemo- and immunotherapy. Lesions with no signs of dysplasia seem to be more recalcitrant and resistant to topical treatment. We hypothesize that this occurs due to a higher cell turnover in lesions with more dysplastic features, making them more susceptible to topical chemo- and immunotherapy.Given that conjunctival papilloma is relatively rare, the majority of data is from reports and series, and no head-to-head comparisons between treatment approaches are yet available for this challenging condition. Hopefully the future will bring effective, new therapeutic options for patients with this condition.


Leptomeningeal carcinomatosis (LMC) is an end-stage disease with poor prognosis. This disease has not yet been reported with sinonasal carcinomatosis. We present a case of a patient who presented with posterior ethmoid/anterior cranial mass which turned out to be poorly differentiated squamous cell carcinoma (SCC). Later the patient presented with enhancement of the spinal roots and a lumbar puncture diagnosed the leptomeningeal spread of her primary disease. After intrathecal chemotherapy and palliative radiation, the patient failed to resist her disease seven months after the diagnosis. We present the first case report of leptomeningeal spread of sinonasal cancer. Although it seems rare, LMC should be on the differential of patients presenting with neurological deficits. Leptomeningeal carcinomatosis (LMC), or carcinomatosis meningitis, is the infiltration of neoplastic cells into the leptomeninges. LMC is a relatively common and lethal complication caused by a variety of cancers, and is reported to occur in 1%-8% of patients with malignancies . SinonasA 66-year-old woman with a past medical history of hypertension presented with progressively worsening right eye visual acuity. Magnetic resonance imaging (MRI) revealed a large, heterogeneously enhancing mass centered in the right posterior ethmoid air cells, extending into the left ethmoid sinus and the right anterior cranial fossa, producing mass effect on the right optic canal and right optic nerve Figure .An endoscopic endonasal biopsy demonstrated a poorly differentiated Epstein-Barr virus (EBV) negative carcinoma. Histologically, the tumor was interpreted as a poorly-differentiated, SCC of the ethmoid sinuses with basaloid features, T4aN0M0  7th edition) Figures -4.Positron emission tomography/computed tomography (PET/CT) performed 15 days after the biopsy did not show any features of nodal or distant metastases. The treatment plan consisted of neoadjuvant fractionated external beam radiation with weekly cisplatin to be followed by definitive surgical resection.The tumor initially responded well to the neoadjuvant radiation and chemotherapy, and decreased in size, from 2.3 x 2.7 cm in greatest dimension to 1.4 x 1.8 cm. However, approximately one month after finishing chemoradiation, and just days before scheduled surgical resection, the patient presented to the emergency department (ED) for low back pain and weakness that radiated to the bilateral lower extremities. An MRI of the cervical, thoracic, and lumbar spine revealed hyperintensities of multiple nerve roots within the cauda equina and T11-12 nerve roots Figure .The MRI was read as most consistent with arachnoiditis, although a differential of prior infection seqeuale and chronic subarachnoid hemorrhage, less likely LMC was provided. Given her disease history and concerning symptoms, a lumbar puncture (LP) was performed, and the cerebrospinal fluid (CSF) was positive for malignant cells, rendering the diagnosis of LMC Figure .Surgery was cancelled and her treatment plan was modified to intrathecal chemotherapy and palliative radiation. The patient ultimately succumbed to her disease seven months after initial diagnosis. Central nervous system metastasis from head and neck cancers is rare. Additionally, only 2% of LMC arises from head and neck cancers. Diagnosis and treatment decisions for patients with leptomeningeal metastasis from solid tumors vary widely across Europe. Standardization of diagnosis and evaluation tools as well as controlled studies to improve the level of evidence for all therapeutic approaches to LM are required . Major fThe primary diagnostic techniques in establishing a diagnosis of LMC include CSF cytology and MRI. It is important to note that a negative result on cytology does not exclude the diagnosis of LMC, and additional attempts at obtaining cytology should be made, as after three attempts, the sensitivity of cytology increases to ~90% [This is a rare occurrence of leptomeningeal spread of SCC of the ethmoid sinus. This diagnosis should be on the differential diagnosis in patients presenting with new neurological deficits.


Presence of vestibular schwannoma and a simultaneous glomus jugulare tumor is an extremely rare event. There is only one case report regarding the incidence of a contralateral vestibular schwannoma, along with a glomus jugulare tumor. Herein, we present the second case with a contralateral tumor. A 69-year-old woman presented with a long history of bilateral hearing loss and a 2-year history of left-sided pulsatile tinnitus. The patient also suffered the itching of the left ear canal and mild vertigo; however, she had no recollection of middle ear infection, ear discharge, or ear pain. Magnetic resonance imaging (MRI) revealed a right-sided 8-mm extrameatal vestibular schwannoma and a left-sided almost purely extracranial glomus jugulare tumor of 18 mm. The pure-tone average values were 63 and 43 dB HL for the right and left ears, respectively. Speech audiometry showed a discrimination score of 76/88 (%). Caloric irrigation was performed and revealed a unilateral weakness of 81% towards the side of vestibular schwannoma. The patient was included in a watchful waiting regimen with annual MRI scans.Though vestibular schwannomas and glomus jugulare tumors are pathophysiologically different, they are similar in terms of symptomatology, growth pattern, diagnostic process, and therapeutic strategy. Based on this case report, it can be concluded that a vestibular evaluation demonstrates a unilateral vestibular weakness towards the side of the vestibular schwannoma, thereby facilitating clinical discrimination between the lesions. They account for around 80-90% of all cerebello- pontine angle tumors (Vestibular schwannomas (VSs) originate from the Schwann cells of the 8e tumors . Most ofe tumors . Based oe tumors .Vestibular schwannomas present an enigmatic growth, which often occurs within the first five years. The large tumors may even remain stable through multiple years ,5.Glomus jugulare (GJ) tumors are slow-growing benign tumors, which can be locally aggressive. Such tumors originate from the paraganglionic cells in the adventitia of the jugulare bulb. The GJ tumors are rare with an annual incidence of 1 case per 1.3 million . Four caA 69-year-old woman presented with a long history of bilateral hearing loss and a 2-year history of left-sided pulsatile tinnitus. The patient also suffered from the itching of the left ear canal and mild vertigo; however, she had no recollection of middle ear infections, ear discharge, or ear pain. Otomicroscopy revealed the presence of a pulsatile purple-colored middle ear mass in the anterior inferior quadrant of the tympanic membrane of the left ear. The right ear had no visible abnormalities.Due to the mild asymmetry in the pure-tone audiometry and the pulsatile tinnitus in the left ear, including the pulsating purple-colored mass, the patient was subjected to magnetic resonance imaging (MRI). The MRI revealed a right-sided extrameatal vestibular schwannoma of 8 mm and a left-sided almost purely extracranial GJ tumor of 18 mm . After tTwo years after diagnosis, the patient experienced the deterioration of hearing and vertigo symptoms. The pure-tone audiometry  showed aThe patient was scanned independently of the standard MRI protocol. The MRI showed stationary dimensions of the GJ tumor; however, the extrameatal size of VS had increased from 8 mm to 12 mm. The patient underwent suboccipital retrosigmoid surgery with intended hearing preservation and the total removal of the VS.th cranial nerve 4. The MRI is the gold standard for the diagnosis of both VS and GJ tumors. Both VSs and GJ tumors are very rare benign neoplasms that commonly present with hearing loss. To the best of our knowledge, there is only one report regarding the incidence of VS, along with a contralateral GJ tumor . The patAlthough the tumors are different in origin, they are similarly managed with observation, radiotherapy, or surgery. Yet, the formerly reported case was managed differently. In this regard, the GJ tumor in the mentioned case was treated with embolization and radiotherapy due to the tumor size, and the VS was subjected to a watchful waiting regimen. In our case, no GJ tumor growth was observed in the patient; on the contrary, she showed the growth of the vestibular schwannoma after 2 years, resulting in the need for active intervention. The patient chose surgery over radiotherapy despite the risk of hearing impairment. Postoperatively, the hearing was initially preserved; nonetheless, the patient experienced a continuous and gradual decrease in hearing on the operated ear. As a result, she was fitted with the contralateral routing of signal hearing aid with satisfactory results. The patient is still under a watchful waiting regimen for the GJ tumor. Based on the follow-up examinations, no growth or change has been observed in the tumor during the last 5 years. Despite the high pathophysiological difference between the VSs and GJ tumors, they have similar symptomatology, clinical presentation, growth pattern, diagnostic process, and treatment strategy. This case report is unique because it is the first attempt to accurately display the audiovestibular contradictions between a VS and a contralateral GJ tumor. Furthermore, no previously published cases of VS and left contralateral GJ tumor have been managed via a surgical approach and conservative regimen, respectively. In this extremely rare case, the outcomes of the two tumors that differed in all aspects, except for site and dimensions, were determined by MRI. Though the hearing loss was bilateral, there was a noticeable asymmetry regarding the speech discrimination score indicating a retrocochlear affection on the VS side. In addition, the severe caloric areflexia signified a vestibular affection that in contrary to a GJ tumor could be explained by VS. Based on this case report, it can be concluded that a vestibular evaluation demonstrates a unilateral vestibular weakness towards the side of the VS, therefore facilitating clinical discrimination between the lesions. Studies investigating new methods to predict the characteristics of the tumors will greatly benefit the patients due to providing the ground for the implementation of a faster intervention, when necessary, and fewer follow-up scans.


Synovial hemangioma of the knee is a rare benign tumor. Very rarely, the growth of bone is affected by long-term neglect of an intra-articular tumor. Our patient had not only various clinical symptoms but also dysplasia of the femoral bone. In this report, we aimed to raise awareness to prevent various disorders arising from an unnoticed or untreated hemangioma occurring within the knee joint.Our patient was a 41-year-old Japanese man who had had occasional discomfort in the right knee since elementary school. Although he had undergone radiography at several hospitals since childhood, no issues were reported; subsequently, he consulted our hospital. We performed magnetic resonance imaging and discovered a mass. The mass was homogeneous with low intensity on T1-weighted sequences and high intensity on T2-weighted sequences adjacent to the medial femoral condyle. The shape of the medial femoral condyle presented with a concavity in axial images, with irregular margins from the patellofemoral joint to the medial femoral condyle. Moreover, by using magnetic resonance angiography, we discovered a second mass. We decided to perform open surgery to achieve complete excision. Histological examination indicated a synovial hemangioma involving a cavernous hemangioma and irregular arteriovenous connections originating from the subsynovial tissue. The patient became asymptomatic after surgery, with no recurrence for more than 4 years.Synovial hemangioma is rare and difficult to diagnose in outpatient examinations because radiography has a limited diagnostic capacity. Magnetic resonance imaging and angiography are very useful. Nontreatment of intra-articular hemangiomas may lead to dysplasia of the bone and various clinical symptoms. Early complete excision may be instituted to reduce these risks of hemarthrosis. Intra-articular hemangioma of the knee is a rare disease , 2. We rseiza position) for the past year. Although he had undergone radiography and MRI examinations at several hospitals since childhood, no issues were reported; subsequently, he consulted our hospital.Our patient was a 41-year-old Japanese man who had had occasional discomfort in the right knee since elementary school. He had no pain at rest, but he experienced occasional pain when moving the knee. The pain had made it difficult for him to sit on his heels  joint level. However, he complained of discomfort proximally, near the patellofemoral (PF) joint to the medial pouch. Careful palpation revealed an elastic soft tissue mass measuring about 3 cm. When his lower leg was hanging down while he was in a seated position, the blood vessels centered on this area became engorged.X-rays showed no obvious findings. MRI showed a mass measuring about 40 × 12 × 15 mm (Fig. en bloc. On the basis of a report of synovial hemangioma occurring outside the knee joint [We performed surgery with the patient under general anesthesia. When his lower leg was hanging down on an operating table, remarkable engorgement of the blood vessels was observed. Arthroscopic examination was performed to confirm the nature, location, and extent of the mass Fig. . The finee joint , our patReports of hemangioma of the knee are rare; furthermore, diagnosis of hemangiomas is difficult and requires considerable time because of the general, nonspecific findings of hemarthrosis, which include localized pain or tenderness, swelling, and limited range of motion , 4–6. Ouet al. have also divided synovial hemangiomas into diffuse and circumscribed types based on the manner of progression of the tumor [et al. classified them as either a diffuse type or a localized type [Painful or hemarthrotic intra-articular hemangioma of the knee is classified into the following two types: synovial hemangioma and arteriovenous malformation , which ahe tumor . Lewis ezed type . Finallyzed type . The juxRegarding assessment, it has been reported that intra-articular masses determined to have noninfectious synovial proliferative processes exhibit specific imaging characteristics . MRI exaReported methods of treatment include embolization , radiothSynovial hemangioma of the knee is rare and difficult to diagnose in outpatient examinations because radiography has a limited diagnostic capacity. If the swelling persists, a joint puncture should be performed, and the joint fluid should be evaluated. If blood is found, hemangioma should be suspected. In that case, both MRI and MRA are useful and should be performed. Nontreatment of intra-articular hemangioma may lead to dysplasia of the bone and various clinical symptoms such as loss of range of motion, catching, and arthropathy. Early complete excision may be instituted to reduce these risks of hemarthrosis.


Traumatic abdominal wall hernias comprise less than 1% of all abdominal wall hernias. We present a 22-year-old male sustaining a traumatic Spigelian hernia resulting from striking a guardrail while snowboarding. In addition, the patient was found to have injuries to the serosa of the small bowel and mesentery, which were repaired during emergent surgery. A hybrid surgical approach was used to repair the defect using both laparoscopy and an incision over the abdominal wall defect. Traumatic abdominal wall hernias (TAWH) are uncommon and occur in less than 1% of all blunt abdominal traumas . TAWH isIn reported cases, traumatic Spigelian hernias have been associated with injuries caused by a variety of mechanisms including handlebar injuries, falls from height, as well as motor vehicle collisions . We presA 22-year-male was transported by emergency medical services from an area ski resort to a regional trauma center. The patient while snowboarding lost control and slammed into the guardrail. The patient complained of severe abdominal pain at the scene and was reported to have an enlarging hematoma in the right lower quadrant of the abdomen. The patient continued to have severe abdominal pain upon presentation to the trauma center. His vital signs on arrival to Arrowhead Regional Medical Center included a blood pressure of 111/87, pulse of 104, temperature of 98.1°F, and respiratory rate of 18 with an oxygen saturation of 99% on room air. On the secondary trauma assessment, a 10 cm by 5 cm bulge over the right lower quadrant of the abdomen accompanied by skin ecchymosis and abrasions was noted Figure . In addi9/L, a hemoglobin of 12.9 g/dl, a hematocrit of 38.1, and platelets of 265 × 109/L. Basic metabolic panel was within normal limits except for a carbon dioxide of 23 mEq/L. Coagulation tests resulted in a prothrombin time of 14.6, international normalized ratio 1.2, and partial thromboplastin time of 22.3. Urinalysis showed trace blood with five to ten urine casts per low power field.The patient had a remote history of attention deficit hyperactivity disorder; however, he was not taking any medication for this condition. During the initial evaluation, he admitted to history of polysubstance abuse on the night prior to the traumatic incident. The urine drug screen confirmed his history of drug use disorder indicating the presence of cocaine, marijuana, and methamphetamine metabolites in his urine. The complete blood cell count demonstrated a leukocytosis of 15.1 × 10Bedside point-of-care ultrasound indicated possible bowel in the right lower abdomen, and the focused assessment with sonography for trauma was positive with trace free fluid in the pelvis. Computed tomography (CT) scan with intravenous contrast of the abdomen and pelvis revealed the presence of small bowel in the abdominal bulge and a defect in the arcuate line compatible with a traumatic Spigelian hernia Figure . The pato laparoscope  was introduced to evaluate the hernia defect (Figure While the patient was undergoing induction of anesthesia, after administration of the paralytic agent, the hernia self-reduced. An incision was made over the skin overlying the hernia and upon dissection through the subcutaneous layer, small bowel was visualized. Through the same incision, a 12 mm trocar was introduced into the abdomen, for laparoscopic insufflation of the peritoneal cavity to further evaluate for other major organ injuries. In addition, a 5 mm incision was made after insufflation in the left upper quadrant of the abdomen and a 30t Figure . The smaAfter evaluating the small bowel for possible injuries, the abdomen was irrigated with normal saline and the fascial defect was primarily closed with simple interrupted sutures. The external oblique and transversalis muscles were used to perform a tissue repair with multiple interrupted sutures Figure . At the Traumatic Spigelian hernias are a rare type of hernia that account for less than 1% of all abdominal wall hernias -6. BluntThe management of TAWH has been evolving overtime. In a patient presenting with an abdominal hernia after blunt trauma, the recommended diagnostic modality of choice is CT of the abdomen and pelvis with intravenous water-soluble contrast . AlthougTraditionally, a midline laparotomy with repair of the hernia and exploration of the abdomen and pelvis has been recommended. However, recent studies have shown that the incidence of injuries that require surgical repair in patients with TAWH varies between 31% and 56% . MoreoveIn another report of 34 TAWH cases, the author revealed that 50% of patients required surgery for associated intra-abdominal injuries . Bowel aThe optimal method of hernia repair, including the use of mesh in repair of the TAWH, is debatable. The two most common methods of repairing traumatic and spontaneous Spigelian hernias are through exploratory laparotomy or incision of the abdominal wall over the defect Table  7-16]. -16. 7-16Using a midline incision provides a better exposure, opportunity to explore other organs, and a chance to close the defect from the inside. However, the impact and outcome of utilizing the midline incision technique compared to incision over the defect itself is not well understood .In this case, we applied a hybrid approach of both laparoscopy and incision over the abdominal wall defect to identify injuries and repair the hernia. Although the use of synthetic and biologic mesh is reported in the acute settings, in this case, we elected to use a primary tissue repair method without the use of mesh .TAWH should be suspected in patients with blunt abdominal trauma presenting with abdominal pain and an obvious abdominal wall bulge. A contrast-enhanced CT of the abdomen and pelvis can show the defect site and presence or absence of abdominal contents in the hernia sac. Although the abdominal bulge may be the most obvious finding on the physical exam and imaging, other more common and life-threatening injuries should not be overlooked ,15. A hiGiven the high number of cases reported in the recent decade, the management of TAWH is evolving. Whether all asymptomatic traumatic hernias should undergo surgical exploration to evaluate for intra-abdominal organ injury with emergent repair of the hernia remains unclear. However, in select patients with no other intra-abdominal injury, a non-operative management with or without delayed repair of the TAWH may be safe and feasible. A combination of open surgical repair of the hernia defect and laparoscopic examination of the abdominal and pelvic content provides an alternative approach to the traditional midline laparotomy.