Tricuspid valve endocarditis is increasing in incidence owing to the prevalent use of intravenous substances. Although most patients respond well to intravenous antibiotics over the course of six weeks, some patients require surgical intervention. A multilayered approach to diagnosis with both transthoracic and transesophageal echocardiography (TEE) is recommended for optimal diagnosis and management. In this article, we report a case of septic shock resulting from tricuspid valve infective endocarditis in a young woman with a history of intravenous drug use who ultimately required cardiothoracic surgical intervention for tricuspid valve vegetation. The sensitivity and specificity of TEE for vegetation on the native valves are about 96% and 90%, respectively. Timely surgical intervention may increase the likelihood of tricuspid valve repair by preventing further destruction of leaflet tissue. Transthoracic echocardiogram (TTE) and TEE have complementary roles in the diagnosis and evaluation of endocarditis. With this case report, we emphasize the importance of multimodality imaging and early surgical intervention to prevent further embolism and destruction of tricuspid valve leaflet tissue. Tricuspid valve infective endocarditis (TVIE) comprises about 10% of all cases of infective endocarditis. It is usually associated with the use of intracardiac devices, central venous catheters, and intravenous (IV) drug use. Tricuspid valve (TV) endocarditis is increasing in incidence owing to the prevalent use of IV drugs. It is estimated that the incidence of bacterial endocarditis among IV drug users is about 1.5-20 per 1,000 per year [A 27-year-old woman with a history of IV drug abuse presented with three days of fever and dyspnea. On exam, she was febrile to 103.2F, tachycardic, with mean arterial pressures in the 50s. Her labs were significant for an elevated white blood cell count of 18.86 cells/mm3. After a witnessed generalized tonic-clonic seizure in the emergency department, she was intubated and admitted to the intensive care unit, where she was started on pressors and broad-spectrum antibiotics for septic shock. Computed tomography of the chest showed multifocal pneumonia with nodular opacities consistent with septic emboli. A transthoracic echocardiogram (TEE) showed a large mobile mass on the TV. Blood cultures grew methicillin-sensitive Staphylococcus aureus (MSSA). Her hemodynamic parameters improved, and she was weaned off of pressors and extubated four days later. Transesophageal echocardiogram (TEE) showed marked thickening of the tricuspid leaflets, with severe tricuspid regurgitation and a large, pedunculated, highly mobile 2 cm vegetation on the body of the septal leaflet , immunologic occurrences such as Roth spots, Osler nodes, glomerulonephritis; predisposing heart defect or IV drug use and vascular phenomena like septic emboli, arterial emboli, conjunctival hemorrhages, splinter hemorrhages, Janeway lesions, etc. ,7. Most Prompt treatment with IV fluids, vasopressors, and empirical IV broad-spectrum antibiotics remains the first line of management in patients with septic shock due to TVIE. Based on the patient’s risk factors, for example, IV drug use, and suspected microorganism(s), empirical IV antibiotics are initiated pending blood culture results and sensitivity. The definitive choice of antibiotics should be tailored towards sensitivity results and usually needed for an extended duration of treatment due to poor penetration of the vegetations/abscesses . TherapyTTE and TEE have complementary roles in the diagnosis and evaluation of endocarditis. Most patients with TVIE are successfully treated with antibiotics. 5%-16% of cases eventually require surgical intervention. The ESC recommends urgent surgery for an isolated vegetation >15 mm and feasible valve repair (Class IIb). The AHA/ACC recommends early surgery for a large mobile vegetation on a native valve (Class IIb). With this case report, we emphasize the importance of multimodality imaging and early surgical intervention to prevent further embolism and destruction of TV leaflet tissue.


Masson’s tumor is a benign tumor that usually arises secondary to vascular trauma or thrombi, leading to vascular proliferation. Masson’s tumors are most commonly reported in the head, neck, and extremities. Cases in the heart are exceedingly rare, with most case reports describing the left atrium as the most common location. Even though the tumor is benign, excision is recommended due to the risk of embolization.This is a case of Masson’s tumor located in the left ventricle. The patient is a 24-year-old female, who presented complaining of palpitations and lightheadedness. Transthoracic echocardiography showed a mobile echodensity in the left ventricle. Cardiac MRI showed characteristics similar to a myxoma. The patient underwent surgical resection and a biopsy showed Masson's tumor. This case report focuses on the histopathological features and imaging findings of Masson's tumor. Masson’s tumor, also known as Intravascular Papillary Endothelial Hyperplasia (IPEH), is a benign and rare tumor that is more commonly seen in the head, neck, and extremities. It can arise in a pure form or within pre-existing lesions (hemangiomas or thrombi). Pathogenesis involves vascular trauma and stasis stimulating vascular proliferation and endothelial hyperplasia within a blood vessel or a lesion; however, in 70% of the cases, there is no identifiable trigger ,2. HistoHistory of presentationThe patient is a 24-year-old female who presented initially to her primary care provider complaining of progressive palpitations of a month duration. The episodes lasted approximately 2-3 minutes and occurred unexpectedly with no identifiable trigger. The patient described them as a “heart-racing sensation with a skipping beat” associated with lightheadedness. She denied any chest pain, shortness of breath, or syncope. Her vital signs were within normal limits, and her physical examination was unremarkable. EKG showed sinus rhythm with no abnormal changes. The echocardiogram (echo) revealed a mobile echodensity in the left ventricle (LV) which was concerning for cardiac myxoma. She was instructed to go to the emergency department for further work-up. Her medical history was significant for gastroesophageal reflux disease on Protonix® 40mg daily and migraines on topiramate 75mg once at night.A repeat echocardiogram with contrast on admission to the hospital demonstrated a normal-sized LV. LV ejection fraction was 55 to 60%. A filling defect was noted in the LV with a size of 1.12 × 0.7 cm which appeared to be close to the mid-inferior wall. All valves were normal. The computed tomography angiography (CTA) coronary angiogram showed normal coronaries with a right dominant system. Thrombophilia work-up was negative.A cardiac MRI revealed a spherical ~8 × 10 × 8 mm hypermobile mass located in the mid-inferior to apical-inferior portion of the cavity of the left ventricle. The mass projected ~13 mm into the body of the left ventricle. The mass appeared to be attached to an incompletely visualized thin stalk with characteristics of a myxoma Figures .The patient underwent open heart surgery for excision of the mass. There were no post-operative complications. On gross examination, the mass measured approximately 1 cm, was fleshy and had an element of thrombus.The pathology report described an organizing thrombus with papillary endothelial hyperplasia (Masson’s tumor) Figure  with immThere are few case reports of IPEH in the heart. Previous cases have been reported in the left atrium (LA) -6. ThereCardiac masses can be challenging to diagnose. Biopsies are invasive so we must rely on imaging to characterize a lesion. Among different imaging modalities, Cardiac magnetic resonance (CMR) is ideal for differentiating soft tissue. There are a few cases describing the appearance of IPEH on CMR. If the tumor arises from a thrombus or hemangioma, you could expect imaging to show characteristics of these. Features of a thrombus typically include no uptake on late Gadolinium enhancement (LGE) and low or high intensity in T1 and T2- weighted imaging . In thisAlthough IPEH is considered a benign tumor, management of left-sided tumors is generally surgical resection due to the risk of embolization . Other fCardiac Masson’s tumor is exceedingly rare with only a few cases described in the left ventricle. Despite advances in imaging, excisional biopsy is still the diagnostic gold standard. This case posed a challenge for imaging interpretation because it was reported as a potential myxoma with observed thrombi characteristics. Although it is a benign tumor, excision is recommended due to the risk of embolization.


Adrenocorticotropic (ACTH)-producing neuroendocrine tumours (NETs) are rarely found in the small bowel, and primary mesenteric NETs have only been reported in a few cases globally. We report the case of a 68-year-old female with ectopic Cushing’s syndrome due to excessive ACTH secretion from small bowel primary lesions and mesenteric metastasis. Initially, only the mesenteric mass was detected on imaging and endoscopy/colonoscopy, and it was only with surgical exploration that the small bowel lesions were found. This highlights the importance of high clinical suspicion and robust investigation when locating NETs. Surgical resection of the affected small bowel and mesentery was the definitive treatment for this patient. Initial hydrocortisone replacement therapy was needed, and subsequent biochemical tests and clinical reviews demonstrated no recurrence. Neuroendocrine tumours (NETs) are derived from neuroendocrine cells and commonly involve the lungs, i.e.,bronchial carcinoma, and the gastrointestinal system, particularly the pancreas but rarely the ileum, mesentery, and liver . MesenteOur aim is to discuss a diagnostically challenging case of small bowel and mesenteric ACTH-secreting NETs that was initially on imaging and endoscopy/colonoscopy thought to be a primary mesenteric lesion but intraoperatively and on histopathology was found to be likely secondary to a small bowel NET.A 68-year-old female was referred by her general practitioner to hospital for critical hypokalemia of 1.7, metabolic alkalosis, and hypertension (180/90 mmHg). Her symptoms included a week of insomnia, intermittent cardiac palpitations at night, unstable balance, and a metallic taste in her mouth. Upon examination, she had cushingoid features of a buffalo hump and central adiposity and no lymphadenopathy. She had a past medical history of recently diagnosed chronic lymphocytic leukemia (CLL), ischemic heart disease, and lower limb deep vein thrombosis (DVT) for which she was taking daily rivaroxaban. She had no significant family history and was relatively active and independent in the activities of daily living. Written informed consent was obtained from the patient to publish this paper.Investigations and management were guided by the endocrinology team. Laboratory testing showed a normal aldosterone:renin ratio, a high ACTH level of 36.6 pmol/L , high morning cortisol levels of 1869 nmol/L, increased 24 h urinary free cortisol 4349 nmol/24 h , and a positive low/high dose dexamethasone suppression test were indicative of ectopic ACTH. She was commenced on oral metyrapone 750 mg TDS which successfully reduced the cortisol level to 319 nmol/L. Tumour markers including AFP, CEA, CA 125, and CA 19.9 were negative. The HbA1c, blood sugar levels, and thyroid function tests were all within normal limits. Her hypokalemia was managed with intravenous and oral potassium replacement and spironolactone. Her hypertension improved with low-dose ramipril.MRI of the brain revealed no pituitary mass or intracranial pathology. The CT chest/abdomen/pelvis was unremarkable and demonstrated no lymphadenopathy or splenomegaly. The thyroid US was unremarkable. A PET Gallium DOTATATE scan demonstrated a DOTATATE avid mass measuring 4.7 × 2.8 cm in the mesentery suspicious for DOTATATE avid malignancy. There were no other suspicious lesions. This is shown in The case was referred to the colorectal department for consideration of surgical resection of the mesenteric mass. A multidisciplinary team discussion with the oncologist, endocrinologist, and surgical teams determined that an endoscopy and a colonoscopy should be performed prior to resection of the mass to further investigate for a possible primary lesion as the consensus was towards the higher probability of a metastatic mesenteric mass even though no primary was found on imaging. The endoscopy demonstrated a normal oesophagus, a regular Z-line, a normal duodenum, and a single gastric polyp that was biopsied demonstrating only moderate chronic inflammation and reactive changes. The colonoscopy was unremarkable. A laparoscopic small bowel resection was performed, and two small bowel nodules were found that were 30mm apart and a mesenteric nodule was located in the distal third of the small bowel mesentery. This is shown in The histopathology revealed that both the small bowel nodules and the mesenteric mass were G1 well-differentiated neuroendocrine tumours of pT4 and pN2. The nodules invaded the visceral peritoneum and were associated with two regional lymph nodes. The surgical margins were clear. The immunohistochemistry showed that the tumours were strongly and diffusely positive for chromogranin, synaptophysin, and CDX2. T1F1 and GATA3 were both negative. Nodule 1 was ACTH-, glucagon-, and gastrin-negative, but somatostatin-isolated-positive cells equaled 1%. Nodule 2 was gastrin- and glucagon-negative; ACTH was scattered positively by only 2%, and somatostatin-isolated-positive cells equaled 1%. The mesenteric mass was ACTH-positive in 50–60% of cells, glucagon-negative, somatostatin-isolated-positive cells equaled <1%, and it was gastrin-negative.Upon follow-up three months later, the patient was well, had ceased all hydrocortisone replacement, and their 1mg dexamethasone suppression test showed normal ACTH < 1.1 and cortisol < 28. There was no evidence of residual ectopic ACTH production.Ectopic Cushing’s syndrome from ACTH-producing NETs commonly originates from intrathoracic small cell carcinomas, medullary thyroid carcinoma, phaeochromocytoma, and pancreas and thymus carcinomas . More un111In-DTPA-Octreotide in detecting NETs [Diagnosis of ACTH-producing NETs includes blood tests particularly high serum ACTH levels with the dexamethasone suppression test, high serum cortisol, and urinary-free cortisol . Clinicaing NETs .Given the rarity of a mesenteric mass being the primary NET, other diagnostic modalities such as a colonoscopy, small bowel series, and scintigraphy can be used . In our NETs have specific immunohistochemistry findings whereby somatostatin, synaptophysin, chromogranin A, and neuron-specific enolase are usually positive . In our The curative management for ectopic ACTH-secreting NETs is surgical resection of the tumour . MedicalSurgical excision of the ectopic ACTH-secreting NET enables preservation of adrenal function in the long term despite initial post-operative corticotropic insufficiency. The important pre-operative considerations required include unambiguous identification and localisation of the NET and the absence of distant metastases . FurtherAs shown in In summary, this case highlights a diagnostically challenging case whereby imaging and endoscopy/colonoscopy demonstrated a solitary mesenteric mass but intraoperative exploration and histopathology revealed two small bowel NETs as primary lesions. Primary mesenteric NETs are extremely rare with only a few cases reported globally; thus, robust investigations and surgical exploration as both a diagnostic and therapeutic procedure must be considered when searching for lesions.


Teaching Point: Caseous calcification of the mitral annulus is a benign mass-like lesion which can mimic cardiac tumor or abscess; therefore, multimodal imaging should be considered, avoiding unnecessary interventions. A 79-year-old female patient with a history of cardiac hypertension presented to the emergency department with abdominal pain. On abdominal computed tomography (CT), a left-sided colitis was demonstrated. Also, an oval-shaped cardiac mass was noted.The mass was located on the posterior edge of the mitral valve, bulging into the left atrium . Bone wiCaseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification (MAC) . It mostCCMA mainly involves the posterior fibrous mitral annulus, where it appears as a toothpaste-like mass with a central region of caseous material and peripheral calcifications. It has a dynamic evolution, where CCMA can transform into MAC. CCMA is a benign entity, but with multimodal imaging it can be differentiated from other cardiac lesions.Transthoracic echocardiography is considered the first-line imaging technique, allowing functional evaluation of the mitral valve. On ultrasound CCMA appears as a smooth, periannular hyperechogenic mass with a central echolucent area, consistent with a caseous content of liquefaction. It shows no acoustic shadow artifacts or vascularisation on color Doppler.Cardiac CT has higher spatial resolution, making it most suitable for confirming calcification. On CT, CCMA will show no contrast enhancement. In case of doubt, when CT is inconsistent with a diagnosis, cardiac magnetic resonance (CMR) allows better tissue characterization. On CMR, CCMA is depicted as a mass with low-signal intensity in both T1- and T2-weighted sequences, reflecting its calcium content. Central to the mass, a zone of T1-hyperintensity can be seen. CCMA shows no contrast enhancement on first-pass perfusion sequences, unlike in tumor or abscess. However, late gadolinium-enhancement imaging may show a slight peripheral enhancement, indicating liquefactive necrosis.CCMA is generally found incidentally, as it is usually asymptomatic. Hence, as it has a mass-like configuration, CCMA is often misdiagnosed as a cardiac tumor or abscess. Therefore, multimodal imaging is useful for diagnosis, avoiding unnecessary surgical interventions.


Teaching Point: In case of acute bleeding caused by a mass located in the vagina, it may be difficult to assess the origin of the mass and determine whether it is benign or malignant; MRI is a useful tool for mass detection, diagnosis, and treatment decision. A 51-year-old female was referred to the gynecologic emergency department for abnormal acute vaginal bleeding. The patient lived abroad, and her medical history was unknown.Physical examination revealed paleness, tachycardia, and hypotension (9/4 mmHg).Gynecologic examination revealed a vaginal mass and active bleeding.Transvaginal ultrasonography was performed in difficult conditions and differential diagnosis included prolapsed submucous uterine fibroid (PSUF), cervical, endometrial, vaginal or endometrial polyp.Biopsies were waived to avoid increasing bleeding, and emergency magnetic resonance imaging (MRI) was performed to determine adequate treatment. MRI sagittal  and axia1000 and normal ADC (1.4 10-3mm2/sec) (white arrow).Axial diffusion-weighted image  and appaSagittal gadolinium-enhanced fat-saturated T1-weighted image shows similar enhancement of the solid components of the mass and the myometrial tissue . SagittaThe diagnosis of prolapsed uterine fibroid was confirmed by MRI and histopathology after surgery.Most PSUF are considered pedunculated fibroids classified FIGO 0. Their incidence is 2.5% and usual symptoms are vaginal bleeding, pelvic pain, cramping, or torsion. Diagnosis can be made with vaginal examination, ultrasonography, computed tomography scan, and MRI.In case of acute gynecological bleeding, differential diagnostic between benign and malignant lesion and location of the lesion  are challenging with gynecological examination and transvaginal ultrasonography.Magnetic resonance imaging enables an accurate diagnosis and prompt surgical treatment.It reveals a mass prolapsed in the cervical and vaginal canal with a stalk attached to the myometrium of the uterine body. The combination of a stalk with prolapsed tumor and its enhancement similar to the myometrium’s enhancement is what is called the broccoli sign .


A self-expandable metal stent is often placed as a bridge to elective surgical treatment of left-sided malignant obstruction of the colon because it allows for primary anastomosis without the need for a temporary stoma, which has a positive impact on the patient’s quality of life. However, although a relatively safe procedure, colonic stenting can have complications that require emergency surgery. This case report describes a rare case of abdominal compartment syndrome that occurred as a complication of endoscopic insufflation during colonic stenting.The patient was a 72-year-old woman who presented complaining of several days of constipation and loss of appetite. Computed tomography of the abdomen revealed obstruction of the sigmoid colon by a tumor. There were no symptoms or computed tomography findings to suggest perforation. Therefore, an attempt was made to insert a self-expandable metal stent. Acute respiratory disturbance and a change in consciousness occurred during the stenting procedure, with marked abdominal distention. Abdominal compartment syndrome was diagnosed and treated by decompressive laparotomy.To the best of our knowledge, this is the first reported case of abdominal compartment syndrome as a complication of endoscopic insufflation during colonic stenting. The possibility of abdominal compartment syndrome should be considered if acute respiratory disturbance or altered consciousness occurs during endoscopic procedure in a patient with malignant bowel obstruction. Self-expandable metal stent (SEMS) implantation is being used increasingly in the management of malignant colorectal obstruction, not only for palliative purposes, but also for preoperative treatment in patients who are candidates for surgery . The cliAbdominal compartment syndrome (ACS) is defined as sustained intra-abdominal pressure above 20 mmHg with new onset of organ dysfunction . The majWe have encountered a case of ACS without perforation caused by tension pneumoperitoneum that occurred because of carbon dioxide insufflation during stenting for malignant colonic obstruction.A 72-year-old woman  presented to our hospital complaining of constipation and loss of appetite in the previous few days. She did not appear to be unwell with a blood pressure of 128/75 mmHg, a heart rate 93 beats/min, a body temperature of 36.6 °C, and a respiratory rate of 22 breaths/min with 99% oxygen saturation in room air. Her Glasgow Coma Scale (GCS) was E4V5M6. Physical examination revealed a distended but non-tender abdomen. Laboratory investigations did not reveal any obvious abnormalities. A computed tomography (CT) scan confirmed marked colonic dilatation caused by cancer in the sigmoid colon  ACS can occur as a complication of endoscopic carbon dioxide insufflation and (2) ACS should be suspected if a sudden change in level of consciousness or respiratory disturbance occurs during endoscopic procedure in a patient with malignant bowel obstruction.Colonic stenting as a bridge to surgery is recommended as one of the treatment options for malignant colonic obstruction in the European guidelines . HoweverThis is the first report of ACS as a complication of endoscopic insufflation during colonic stenting. In this case, the sigmoid colon cancer acted as a one-way valve, trapping the air delivered by the colonoscope and causing remarkable intestinal dilation and pneumoperitoneum without perforation, resulting in ACS. Pneumoperitoneum has been reported to occur at rates of 0.3%–1% in diagnostic colonoscopy and 3% in therapeutic colonoscopy . Most caPerforation at the time of stent insertion is a major complication requiring surgery and often manifests as abdominal pain or subcutaneous emphysema one hour to one day later , 14. HowACS is usually caused by rapid addition of volume , in whicWe have reported the first case of ACS as a complication of endoscopic carbon dioxide insufflation during colonic stenting. Acute respiratory failure or change in consciousness during this procedure should raise suspicion for ACS.


Desmoid-type fibromatosis (DF) is a rare monoclonal, fibroblastic proliferation characterized by an unpredictable and variable clinical course. We present the case of a 56-year-old woman who underwent total thyroidectomy for papillary thyroid carcinoma in 2012 and who developed a cervical mass at the left laterocervical level during follow-up, raising the diagnosis of tumor recurrence. Computed tomography of the neck showed solid formations with heterogeneous contrast uptake in the right lateral region of the neck. At the level of the thoracic operculum, a second 26-mm formation was observed that medially contacted the left lateral wall of the trachea. Lateral lymphadenectomy was performed, which was incomplete. Histology showed findings consistent with desmoid-type fibromatosis. DF are slowly proliferating, non-metastatic tumors with a highly invasive capacity that are usually present in familial adenomatous polyposis (FAP)-Gardner syndrome. Our case had a historyof massive colonic polyposis and first-degree relatives of colorectal cancer. Puede clasificarse en diferenciados, pobremente diferenciado e indiferenciado. Habitualmente, los tumores diferenciados (papilar y folicular) tienen buen pronóstico. Sin embargo, un porcentaje de pacientes pueden evolucionar hacia una persistencia o recurrencia de la enfermedad. Al respecto, la aparición de una lesión a nivel cervical plantea, como primera hipótesis diagnóstica, la recidiva tumoral ya que la fibromatosis de tipo desmoide es una entidad infrecuente.They lack metastatic potential, they are locally invasive and cause significant morbidity and mortality. The incidence is 2–4 per million population and accounts for 0.03% of all neoplasms.Desmoid-type fibromatosis (DF) is a rare monoclonal, fibroblastic proliferation characterized by an unpredictable and variable clinical course.CTNNB1 encoding β-catenin is found in most sporadic DF cases and constitutional mutations of APC have been described as hereditary in patients with FAP.The etiology of DF is unknown. Although most DF occurs sporadically, DF is seen at increased frequency in familial adenomatous polyposis (FAP). A mutation of the Extra-abdominal desmoid tumors comprise a third of desmoid tumors and usually occur in the shoulder, pelvic girdle, and limbs. Only 10-25% of extra-abdominal desmoid tumors developed in the head and neck region. The management of DF is challenging and requires a discussion at a multidisciplinary tumor board.According to its location, DF is classified into three types: intra-abdominal, abdominal, and extra-abdominal.We present the case of a 56-year-old woman who underwent total thyroidectomy for papillary thyroid carcinoma and developed a cervical mass during follow-up.A 56-year-old female patient with a history of papillary thyroid carcinoma for which she underwent total thyroidectomy in 2012 and received I131 (cumulative dose of 450 mCi) and who evolved after five years of follow-up with the appearance of a cervical mass on the left later cervical level, raising the diagnosis of tumor recurrence. She had no allergies and had been a smoker (20 packs/year). Among other antecedents, she presented massive colonic polyposis and a first-degree family history of colorectal cancer.After the initial surgery, the biopsy revealed a 4-cm papillary carcinoma of a predominantly classic and focally follicular pattern located in the left thyroid lobe and several scattered microscopic satellite lesions in the rest of the thyroid parenchyma with focal thyroid capsular infiltration, without exceeding it. Angiolymphatic invasion images were not observed.The patient was under treatment with levothyroxine (LT4) at a dose of 200 μg/day and presented in the laboratory with a TSH of 0.744 μIU/ml, T4l 1.29 ng/dl, thyroglobulin 5.1 ng/ml and ultrasensitive antithyroglobulin 3.04 IU/ml (<150 IU/ml). On physical examination, she presented a left later cervical lobulated mass measuring 8 by 5 cm, with a hard elastic consistency, and partially adhered to deep planes. A neck computed tomography with intravenous contrast was requested, in which solid formations with heterogeneous contrast uptake were observed in the left lateral region of the neck, the largest of 40 mm, and located behind the primitive carotid artery and in close contact with the left jugular vein, producing an extrinsic compressionand a decrease in its caliber. Caudally to this formation, at the level of the thoracic operculum, a second 26-mm formation was zobserved that contacted medially with the left lateral wall of the trachea and, behind, with the primitive carotid artery.A fine needle aspiration biopsy (FNAB) was performed which is not conclusive and a surgical resolution was decided, proceeding to a left lateral lymphadenectomy that was incomplete. Histology demonstrated the presence of important connective changes of the hypertrophic type of scar repair with the presence of inflammation. Among the fibrous tissue, areas of fusiform elements with a proliferative appearance were observed in parallel layers, without atypia and with an infiltrative arrangement on the adjacent tissues. These findings were consistent with desmoid-type fibromatosis. The eleven lymph nodes analyzed presented non-specific reactive lymphoreticular hyperplasia Likewise, considering the first-degree history of thyroid cancer, massive colonic polyposis, the presence of desmoid-type fibromatosis and thyroid cancer, the diagnosis of Gardner syndrome is considered and genetic tests and orthopantomography are requested.. DFs are poorly circumscribed masses that infiltrate the surrounding soft-tissue structures. They are formed by a myxoid stroma containing elongated and uniform spindle cells, which present rare mitotic figures.No differences are found between extra- and intra-abdominal DF, neither in their histology nor in their clinical behavior. We present a patient with a history of thyroidectomy for thyroid cancer who, on follow-up, developed a neck mass with a histopathological diagnosis of DF. This is the fourth case of a DF after thyroidectomy.(7-9), and the third after total thyroidectomy.DF are slowly proliferating, non-metastasizing tumors with a highly invasive capacity, which can be life-threatening in the case of intra-abdominal retroperitoneal localizationAPC gene's germline mutation, which is transmitted in an autosomal dominant manner with nearly 100% penetrance.The incidence ranges between 1:6,850 and 1:23,700 live births.Affected people will develop hundreds to thousands of small adenomatous colonic polyps. It is characterized by an increased risk of extra-intestinal manifestations, such as osteomas, congenital hypertrophy of retinal pigment epithelium, gastric and duodenal polyps, thyroid and pancreatic cancer, adrenal cortical adenoma, hepatoblastomas, medulloblastoma or glioblastoma.For this reason, it is recommended that patients with FAP be evaluated with an annual thyroid ultrasound from the age of 15 to 20 years. DF affect 10-15% of patients with Gardner syndrome.Our index case had, in addition to thyroid cancer, a history of massive colonic polyposis and first-degree relatives of colorectal cancer. Although the diagnosis of Gardner syndrome was highly suspicious, ophthalmological studies and orthopantomography were normal. The patient was referred for genetic counseling to assess the genetic mutation study and the indication for prophylactic colectomy. Unfortunately, definitive diagnosis could not be reached due to the lack of availability of the mutational study of the APC gene.DF are usually present in familial adenomatous polyposis (FAP)-Gardner syndrome. FAP is a hereditary cancer syndrome caused by the However, our patient presented DF in the neck. In the context of aDifferently from sporadic DF, FAP-associated DF are mainly intra-abdominal (80% of cases) or at the abdominal wall, while extra-abdominal DF accounts for about 5% of patients.history of thyroid cancer, this cervical mass's appearance raised the tumor recurrence diagnosis. Therefore, we performed a FNAB that was not conclusive, requiring surgery, obtaining the diagnosis of DF.Unlike other soft-tissue sarcomas where the goal of surgical resection is to achieve a microscopic negative margin (R0 resection), an R0 resection is only deemed desirable, but not a necessity in the surgery of a DF. Although positive margins after surgery have been reported as an independent prognostic factor for recurrence, guidelines prohibit a morbid surgery from achieving an R0 resection.In combination with RT and medical therapy, the surgical treatment of DT has become more and more conservative. Therefore, RT is primarily used in the adjuvant setting when surgery leaves behind a positive margin, or when surgical resection is not possible.In our case, total surgical resection was not possible, therefore, adjuvant radiotherapy was considered.The approach to DF is primarily surgical.Our patient did not show DF in the primary tumor or in the lymph nodes evaluated later.Finally, a rare variant of papillary carcinoma with a DF component has been reported. However, a dual tumor with a classic CPT component with malignant epithelial proliferation and another component with mesenchymal proliferation is necessary.DF are locally aggressive clonal proliferations of mesenchymal tissue. They lack metastatic potential, but their locally aggressive behavior can be associated with several complications. In the setting of FAP-syndrome, DF of the head and neck are quite rare and are often incompletely removed with grossly or microscopically residual disease. Only four cases were reported after thyroidectomy.


Neuroendocrine neoplasms (NEN) of the head and neck are a rare and diverse group of tumors. Here, we report a case of a 40-year-old man presenting with symptoms resembling chronic left otitis media, including left ear otorrhea, otalgia, and reduced hearing. Otoscopic examination revealed a whitish mass located behind the tympanic membrane. The patient underwent examination under anesthesia and left cortical mastoidectomy, and a histopathological examination of the middle ear biopsy indicated the presence of an epithelial tumor with neuroendocrine differentiation, suggestive of middle ear adenoma. A staging CT scan performed three months after the mastoidectomy showed a hypodensity in the middle ear cavity, with no significant bony erosion, which could potentially indicate a residual or recurrent tumor. Consequently, a radical mastoidectomy was performed. The histopathological examination confirmed the presence of middle ear adenoma with neuroendocrine differentiation. Middle ear adenoma is a benign tumor, but there is a risk of recurrence and malignant transformation. It is a rare disease, with approximately 150 cases published in the literature to date . The gasA 40-year-old man with underlying hypertension presented with a nine-month history of left otorrhea, ear blockage, otalgia, and reduced hearing. He denied experiencing tinnitus, vertigo, facial weakness, or fever. Initial examination revealed signs of left otitis media, including the identification of pus in the middle ear and a bulging tympanic membrane bulging. He was initially treated with oral antibiotics for a duration of one week. However, the left ear blockage and pus discharge persisted. The initial hearing assessment showed severe to profound mixed hearing loss in the left ear, with a type B tympanogram. Additionally, there was mild sensorineural hearing loss at high frequency with a type AD tympanogram in the right ear. Subsequent otoscopic examination demonstrated resolved otorrhea and visualization of an opaque mass behind the tympanic membrane Figure . A high-Examination of histological sections stained with hematoxylin and eosin revealed that tumor cells were arranged in sheets with a glandular and focal cribriform pattern Figure . The tumPostoperatively, the patient continued to experience persistent reduced hearing in the left ear, but there were no symptoms of otalgia, otorrhea or facial weakness. Otoscopy examination revealed tympanosclerosis, characterized by a dull tympanic membrane and a whitish opaque mass behind it. A staging CT scan conducted three months after the mastoidectomy exhibited a hypodensity in the middle ear cavity, with no significant bony erosion. This finding raised the possibility of residual or recurrent tumor. Consequently, a radical mastoidectomy was performed. During the surgery, an abnormal bony component was identified at the anterior inferior part of the middle ear Figure . The lesHead and neck NEN are a rare and diverse group of tumors. NEN in the middle ear are particularly uncommon, as epithelial cells with neuroendocrine features typically do not reside there . The gasThere is no significant gender difference, and middle-ear neuroendocrine tumors (NETs) can occur across a wide age range without specific symptoms or findings. Typically, patients present with unilateral conductive hearing loss, ear fullness, tinnitus, and dizziness . ConsistThe differential diagnosis of middle ear NETs includes acoustic neuroma, rhabdomyosarcoma, jugulotympanic paraganglioma and adenocarcinoma . RadioloMacroscopically, MENETs are typically unencapsulated and exhibit a soft, rubbery to firm consistency. They can appear as white, grey or red-brown in color and are usually smaller than 1 cm in size ,12. MicrFunctional NETs typically manifest with symptoms related to the overproduction of hormones by the neoplasm, such as insulinoma, glucagonoma and VIPoma. Diagnosis of these tumors can be achieved through mono analyte testing. However, for non-functional tumors, there are currently no universally available biomarkers . In our Surgery, with or without removal of ossicles, is the treatment approach for this rare condition. Previous reports have indicated a local recurrence rate of 12.7%, which may necessitate additional surgical intervention. Radiation, chemotherapy and somatostatin analogues are typically employed in the management of pulmonary or gastrointestinal carcinoids .Middle-ear adenomas are rare neoplasm. Surgical resection is typically the primary treatment, and microscopic, and immunohistochemical examinations are necessary for a definitive diagnosis of middle ear NETs. Long-term follow-up is recommended to monitor for residual tumors, late recurrence, and metastatic disease. It is crucial for ENT surgeons to not only consider chronic otitis media in patients with frequent discharge but also to investigate and rule out the possibility of tumors.


Dirofilaria spp. The number of cases of human dirofilariosis reported in the last 50 years has gradually increased. Dirofilaria repens is now endemic in many countries and is currently considered to be one of the fast spreading zoonoses in Central, Eastern and Northern Europe. The first empirical evidence of Swiss spreading of D. repens infections was in a dog from southern Switzerland in 1998. Ours is the first case of human orbital dirofilariosis found in a Ukranian patient reported in Switzerland. Our purpose is to inform the ophthalmologist to consider orbital dirofilariosis in the differential diagnosis of inflammatory masses of the orbit and to warn about the spread of this infection in Switzerland.A 78-year-old Ukrainian woman who had immigrated to Switzerland presented with a rapid growing subcutaneous infraorbital mass. Surgical excision of the mass revealed a well-circumscribed, encapsulated tumor, adherent to the skin. The excision showed a soft tissue inflammation with parts of  A wide variety of processes can produce space-occupying lesions in and around the orbit. These include benign neoplasms, malignant neoplasms, vascular lesions, inflammatory disease, congenital lesions, and infections, among other causes. Imaging can be used to precisely localize a lesion, to help establish a diagnosis or generate a differential diagnosis that guides management, to follow a known lesion for progression, or some combination of these .In this report we describe a case of a rapidly growing subcutaneous infraorbital mass—masquerading as orbital tumor—secondary to a dirofilariosis.This case report was prepared in accordance with the principles of the Declaration of Helsinki. As this article pertains only to a case report, specific ethics approval is not mandated. Written informed consent was taken from the patient to publish the photographs before inclusion in the article.Dirofilaria spp., probably Dirofilaria repens. The postoperative course went well and the patient had no complaints after the surgical excision of the mass.A 78-year-old Ukrainian woman, who had moved to Switzerland about 6 months ago complained of a three-week history of sudden, relatively painless swelling in the lower right orbit . At the Dirofilaria repens is a nematode affecting domestic and wild canids, transmitted by several species of mosquitoes. It usually causes a non-pathogenic subcutaneous infection in dogs and is the principal agent of human dirofilariosis in Europe [D. repens has increased in prevalence in areas where it has already been reported and its distribution range has expanded into new areas of Europe, representing a paradigmatic example of an emergent pathogen [n Europe . In recepathogen .Dirofilaria spp. to Central Europe. Dirofilaria repens is now endemic in many countries in the region , and is currently considered to be one of the fastest spreading zoonoses in Central, Eastern, and Northern Europe [In the ophthalmology literature, the number of cases of human dirofilariosis reported in the last 50 years has gradually increased. Global warming in particular, has created conditions favoring the development of infective larvae in mosquitoes, and facilitated the recent spread of n Europe ,5. In Ukn Europe .D. repens infections was found in a dog in southern Switzerland in 1998. A few years later, another two positive dogs were found in Canton Ticino in 2001 [The first empirical evidence of Swiss spreading of  in 2001 ,8.Dirofilaria repens is a common parasite in dogs, which constitute the main source of infection. Humans are accidental hosts and many infected subjects are asymptomatic [Aedes, Culex, or Anopheles mosquitoes carrying infective larvae acquired from the microfilariae-rich blood of animal hosts parasitized with either deep-seated or subcutaneous worms of the Dirofilaria spp. In humans, the nematode causes a subcutaneous or superficially located inflammatory reaction that traps it within a nodule, where it may survive for many years [ptomatic . Transminy years . Such leDirofilaria repens is well known to affect the eye and the ocular adnexa [Dirofilaria worm in the conjunctiva of a Sicilian woman and called it Dirofilaria conjunctivae. The largest series of cases–six with periocular involvement of D. repens—was described by Font in 1980 [D. repens; however, based on histologic criteria alone, in the differential diagnosis an onchoceriasis has to be considered. Onchocerca lupi (zoonotic) is also present in Europe. In the present case, the morphology of the parasite makes us think with high probability of an infection with D. repens; the morphological distinctive characters of female nematodes allow a straightforward identification. Onchocerca lupi presents a thick cuticle composed of an external layer bearing prominent, undulated annular ridges and an internal layer with transverse striae [D. repens, which has longitudinal crests. Since O. volvulus occurs mainly in Africa, with additional foci in Latin America and the Middle East, the present case represents, with a very high probability, D. repens infection rather than an onchocerciasis.r adnexa . The infr adnexa , an Ital in 1980 . More re in 1980 , conjunc in 1980  and a 35 in 1980  and a su in 1980 . A case  in 1980  and a ca in 1980 . Our casIn the literature there are 38 up-to-date reported cases of ocular/orbital/eyelid dirofilariosis. The majority of articles were case reports of up to three patients, with the exception of Dzamic et al.  who presDirofilaria spp. are the size and the features of the body wall, i.e., thickness of the cuticle and its structure, ridges, lateral chords, and number and type of muscle cells [In general, the diagnosis of human dirofilariosis is based on histologic examination. Useful characteristics for differentiating between the different le cells .Usually, the clinical symptoms disappear after the parasite is removed and no adjunct therapy is necessary .This is the first report of human infraorbital dirofilariosis masquerading as an orbital tumor found in a Ukrainian patient reported in Switzerland. D. repens [D. repens in non-endemic areas.Climate change affecting mosquito vectors and the facilitation of pet travel seem to have contributed to this expansion; however, the major factor is likely the rate of undiagnosed dogs perpetuating the life-cycle of . repens . Many inBecause the clinical onset of orbital dirofilariosis is usually marked by common symptoms of orbital inflammation such as redness and swelling, ophthalmologists are advised to consider this parasite in the differential diagnosis of inflammation of the orbital tissues. The differential diagnosis in these cases incudes dermoid cysts, sarcoidosis, idiopathic pseudotumor, benign and malignant tumors including metastatic disease.The purpose of this report is to inform ophthalmologists to consider orbital dirofilariosis in the differential diagnosis of inflammatory masses of the orbit and to warn about the spread of this infection in Switzerland.In our view, it is critical to register all new cases in order to assess the epidemiological status and raise awareness of this rare infection.


We report a rare case of a 57-year-old female patient with intraluminal tracheal obstruction caused by a benign schwannoma. She underwent successful bronchoscopic resection under general anesthesia, with no complications observed during the post-procedure follow-up. Tracheal schwannomas are exceedingly uncommon, and while conventional treatment involves surgical resection, bronchoscopic techniques, such as laser ablation, can be a valuable alternative, particularly for high-risk patients. Further studies are needed to explore the full potential of bronchoscopic interventions in managing tracheal schwannomas. Here, we present a unique case of an uncommon tracheal lesion, eventually diagnosed as a benign schwannoma, which is a rare tumor originating from myelinating cells known as Schwann cells. Given its exceptional location and the suspicion of it being a benign lesion, the medical team opted for an endoscopic procedure using argon recanalization. Later, it was realized that the etiology of the lesion was a rare case of tracheal schwannoma.This article delves into the diagnostic challenges, therapeutic decisions, and patient's positive outcomes, highlighting the significance of embracing innovative techniques to manage unique clinical scenarios. By sharing this remarkable case, we contribute to the collective knowledge of pulmonology and underscore the value of multidisciplinary collaboration in advancing patient care for a healthier future.A 57-year-old female patient was admitted to the pulmonology department due to a three-month history of dyspnea on exertion , associated with a persistent dry cough and a weight loss of approximately 5 kg in the past year. She had been evaluated at an outpatient clinic where her primary care physician had performed a chest tomography that showed an endoluminal image in the trachea (see Figure Bronchoscopy was performed for evaluation and biopsy. An irregular, exophytic, sessile, mucoid, vascularized lesion was identified at 6 cm distal from the vocal cords, with an extension of approximately 1 cm, that occluded 35% of the lumen (see Figure Samples were taken for microbiology, and seven biopsies were performed, reporting lymphocyte-predominant inflammation, without microbiologic isolates. A contrast-enhanced chest and abdominal tomography was performed on the patient, showing a single lesion, that had not grown in the last three months and without infiltration into deep tissues. Given those characteristics, the absence of initial malignancy on histology, and the possibility of a granulomatous lesion in the trachea, it was decided to schedule an endoscopic resection.She was taken for bronchoscopy and debulking, a procedure that was performed under general anesthesia, with the use of an N4 laryngeal mask. A Fuji therapeutic bronchoscope was used to recanalize with argon, achieving a complete resection and permeating the lumen (see Figure After discharge, the pathology report revealed a well-limited, benign nerve sheath lesion (see Figure Intraluminal obstruction of the trachea is a low-prevalence clinical entity that usually has a benign origin. Conversely, primary tracheal tumors are mostly of malignant origin, with a reported prevalence of 0.1 per 100,000 persons/year, representing less than 0.5% of all malignant tumors [Schwannomas are encapsulated tumors of the peripheral nervous system, originating from Schwann cells, which rarely have malignant progression . BetweenThe standard of treatment described for this lesion is surgical circumferential resection with tracheal reconstruction. However, schwannomas can be treated using bronchoscopic techniques, mainly laser ablation, with great success in completely intraluminal and pedunculated tumors, especially in patients with high surgical risk . In the A case of tracheal lesion initially identified by tomography is presented. After direct visualization with fiberoptic bronchoscopy and biopsy, it was possible to diagnose a tracheal schwannoma, treated with endoscopic management with excellent results.


Bowel intussusception is rare in adults and is usually driven by an underlying pathological process affecting the bowel. Renal cell carcinoma (RCC) is the most common type of kidney cancer and its disease course, depending on the initial histology and disease stage, can metastasize to adrenal glands, lungs, bones, brains and contralateral kidney that can be challenging to follow.We present the case of a patient with a history of radical left nephrectomy for RCC that developed an acute bowel obstruction, secondary to an ileal metastasis of RCC. In previous surgeries, small bowel obstruction (SBO) is usually found due to adhesions, nonetheless in a patient with a history of high-grade disease at diagnosis, one must keep in mind the possibility of disease relapse in the setting of SBO. Bowel intussusception refers to the telescoping of a proximal segment of the gastrointestinal tract (GI tract) within the lumen of the adjacent segment. It is more frequent in children, whose treatment is conservative many times.In adults, who have a lower incidence rate , usually, there's an underlying lesion explaining the intussusception . Given the non-specificity of the symptoms, sometimes it bears a late diagnosis and surgical intervention is usually advised [Renal cell carcinoma (RCC) accounts for 3% of all adult cancers, urologic cancer being the most lethal. Given today’s early detection on routine exams, the triad of hematuria, flank pain and fever is rare. Of the newly diagnosed RCC with clinically localized disease, 20-40% of patients will develop metastasis. Metastases originating from RCC infrequently occur in the small intestine and typically manifest as either obstructive symptoms or iron deficiency anemia caused by covert bleeding. Metastatic RCC causing intussusception of the small bowel is an uncommon occurrence with limited documentation in the medical literature ,2,4.We present a case study of a patient who was diagnosed with metastatic renal carcinoma in the small bowel and presented to the Emergency Department exhibiting obstructive symptoms caused by intussusception.Here we present a case of a female patient, 51 years old, with a history of open left nephrectomy for RCC. The histology showed a clear cell carcinoma with invasion of the renal vein . She had disease progression at one year of follow-up with pulmonary metastasis and paramediastinal mass, already having been submitted to anti-algic radiotherapy and on palliative Sunitinib.One year and four months after the initial surgery, she presented to the Emergency Department (ER) with a history of colic abdominal pain for the last two days, progressively worsening, and becoming constant and localizing to the right inferior quadrant of the abdomen. She also described anorexia for the last three days and vomits for the last two days. She also reported stopping to pass fecal content the day before in the morning. Her vital signs were stable. Apart from the pain and distended abdomen, the patient revealed no signs of sepsis. The blood gas analysis performed on admission was negative for hyperlactacidemia.Physical examination revealed a distended abdomen, painful at deep palpation, with signs of peritoneal irritation on the right iliac fossa. The blood analysis revealed a slight anemia (Hgb 10 g/dl), with a normal renal function (Creatinine 0.8 mg/dl).Given the oncologic context and the findings at physical examination, the patient did a computerized tomography (CT) scan that revealed an occlusive process of the ileum by a polypoid neoformation with intestinal intussusception Figure .The patient was proposed for an emergency exploratory laparotomy that revealed an abnormal mass in the ileum causing the intussusception, and was submitted to a partial enterectomy encompassing the area with primary anastomosis Figure .She was left on a zero diet on the first 24 hours of post-op period, after which she was allowed to resume liquid intake, with abdominal palpation revealing no signs of peritoneal irritation. Five days later and already on a general diet with normal bowel function, the patient was discharged.The histological analysis of the ileal segment revealed a metastasis from RCC, consistent with the progression of the disease Figure . No immuToday, at eight months follow-up from the last surgery, the patient has shown pulmonary disease progression and is waiting for approval for Axitinib.Bowel intussusception is rare in adults , and is mainly diagnosed in children, in whom conservative management warrants good results. On the other hand, when it presents in adults, it almost always implies surgical management in order to resolve the obstruction and to find out the mechanism behind it. Even though benign lesions are more frequent as the underlying cause, secondary lesions are also a possibility -3.CT scan is the exam of choice, given its diagnostic accuracy and sensitivity that could reach 80-90% and also the information we can take from it, mainly length, localization, vascular impairment, staging and the existence of a lead point starting the obstruction .The confirmation of the diagnosis is usually made on the operating table. When treating such a condition, many times there is a need for gastro-intestinal resection in order to re-establish normal transit .RCC metastasization can appear long after the surgery and common metastasization sites include the lungs, liver, bones and brain. Viadana et al. in 1976 suggested that metastasization of RCC firstly involves the lung through the renal vein and inferior vena cava. From there, it may spread to anywhere in the body . Only 0.This case is worth noting given the rarity of such presentation of metastatic RCC that could be missed by the practicing physician if one does not keep a high level of suspicion. Diagnosis of GI metastatic lesions from RCC is often delayed - they are discovered as the result of its clinical presentation ,3. In a Other cases presenting in the same manner have been treated consistently with enterectomy encompassing the lesion . The proMetastatic RCC lesions to the GI tract are rare and poorly impact the long-term prognosis. Whenever there is a clinical suspicion of intestinal intussusception in an adult, prompt surgical exploration is advised in order to resolve the obstruction and the underlying defect causing it. This case presents an uncommon metastasization site of RCC, with symptomatic acute intestinal obstruction. It enlightens us to thoroughly revise RCC patients whose disease characteristics prompt them to a higher risk of metastatic progression, keeping in mind the possibility of GI symptoms precluding signs of relapsing.


Pneumoperitoneum is often treated as a surgical emergency as the most common etiology is perforated hollow viscus. Here, we present the case of a man in his 70s who presented to the emergency department with fever and abdominal pain. On physical exam, he was diffusely tender in the bilateral lower quadrants with guarding. Imaging demonstrated moderate volume pneumoperitoneum. On review of his imaging, the pneumoperitoneum was centered around a 7 cm necrotic lymph node. Repeat CT scan with positive oral (PO) and rectal contrast demonstrated no extraluminal contrast extravasation, but air bubbles were seen extending from the necrotic lymph node into the lower abdominal cavity. He underwent CT-guided drain placement and was started on antibiotics, and improved without surgical intervention. In stable patients presenting with pneumoperitoneum and known intra-abdominal lymphadenopathy, perforated viscus should be ruled out prior to surgical intervention, and necrotic intra-abdominal lymph node should be considered as a differential diagnosis. Surgical dogma teaches that pneumoperitoneum, or air within the abdominal cavity, is a surgical emergency demanding operative exploration as the most common cause is perforated hollow viscus . There aA man in his 70s presented to the emergency department with several days of subjective fever and abdominal pain. His medical history was significant for diffuse B-cell lymphoma on chemotherapy, permanent atrial fibrillation on Eliquis, and recent admission for chemotherapy-induced pneumonitis, for which he was discharged on high-dose steroid taper. On physical exam, he was tender to palpation in the bilateral lower quadrants with guarding but without signs of peritonitis. Laboratory analysis was significant for a white blood cell count of 4.4 K/mcl. Computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast demonstrated moderate volume pneumoperitoneum Figure .On review of his imaging with radiology, the pneumoperitoneum was centered around a 7 cm necrotic lymph node identified on a CT scan of the abdomen and pelvis one month prior, which was completed to monitor response to chemotherapy. Given his hemodynamic stability and absence of peritonitis, a repeat CT scan of the abdomen and pelvis was obtained with oral and rectal contrast to rule out hollow viscus perforation. No extraluminal contrast extravasation was identified, but air bubbles were seen extending from the necrotic lymph node into the lower abdominal cavity Figure .Enterobacter cloacae. He was started on an extended course of cefepime per infectious disease team recommendations and was ultimately discharged to the inpatient rehabilitation unit on hospital day seven. The patient was admitted to the medicine service with interventional radiology and infectious disease consultation. The general surgery team continued to perform serial abdominal exams. On hospital day one, he underwent CT-guided percutaneous drain placement with return of thirty milliliters of purulent material. This was sent for culture and eventually grew Patients with pneumoperitoneum frequently present with abdominal pain and, depending on the source of the air, may also present with nausea, vomiting, fever, or sepsis . Given tIn patients presenting with pneumoperitoneum, there should be a high index of clinical suspicion for perforated hollow viscus; however, there are causes of pneumoperitoneum that do not require surgical intervention. There are no reported cases of pneumoperitoneum secondary to necrotic intra-abdominal lymph nodes in the literature. Given this patient's multiple co-morbidities requiring Eliquis and high-dose steroids and his current chemotherapy treatment, operative intervention would have increased his risk of morbidity and mortality. Based on the American College of Surgeons surgical risk calculator, which uses patient-specific risk information using twenty patient predictors and the planned procedure to predict any of eighteen different outcomes within thirty days following surgery, undergoing exploratory laparotomy would have carried a 36% chance of any complication compared to an average risk of 20% and a 21% risk of mortality compared to an average risk of 4% [In stable patients presenting with pneumoperitoneum and known intra-abdominal lymphadenopathy, perforated viscus should be ruled out with oral and rectal contrast prior to surgical intervention, and necrotic intra-abdominal lymph node should be considered as a differential diagnosis.


Meningiomas are the most prevalent tumors within the central nervous system, with most exhibiting benign characteristics. While they are often discovered incidentally, their growth can lead to symptoms such as headaches, visual changes, dizziness, and seizures. Intratumoral hemorrhage (ITH) within meningiomas is a rare occurrence. This phenomenon carries a poor prognosis, as evidenced by significant rates of morbidity and mortality. This case report describes a unique case of a 52-year-old male who experienced a spontaneous right parietal lobe intracerebral hemorrhage adjacent to the superior sagittal sinus. Subsequent investigations revealed this to be an ITH due to an underlying WHO-grade I meningioma. This case emphasizes that while ITH in meningiomas is rare, prompt recognition and surgical intervention ensure optimal patient outcomes. Meningiomas are extra-axial tumors that originate from arachnoid cap cells. They are the most common type of tumor found within the central nervous system, accounting for roughly 37% of primary central nervous system tumors . Most haSpontaneous hemorrhage occurring within a brain mass, also known as intratumoral hemorrhage (ITH), is a rare entity, occurring in an estimated 1.4% to 10% of all intracranial tumors . This phThe most common locations of meningiomas associated with spontaneous ITH are thought to be intraventricular and convexity . The mosA 52-year-old right-handed Caucasian male presented to the hospital with a chief complaint of occipital headaches starting three days prior to evaluation. His headaches were intermittent, fluctuating between 5-8/10 in severity, and dependent upon activity. For example, two days prior to the presentation, he noticed the severity of his headaches dramatically worsened while exercising but resolved 15 minutes after he stopped exercising. He described the pain quality as "sharp" and "stabbing." He stated that the location of his pain is constant, pointing to the exact location overlying the tumor. He denied nausea, vomiting, changes in vision, seizure-like activity, focal weakness, numbness, tingling, or any type of abnormal sensation.He denied having any medical conditions or prior surgeries. He took no home medications (including over-the-counter), had no allergies, and smoked marijuana, but denied tobacco or alcohol use. He denied having any family members with a history of bleeding disorders or cancer. A complete and thorough neurological exam was conducted, and the only deficit appreciated was a mild upgoing drift in his left upper extremity. Otherwise, his Glasgow coma score (GCS) was 15, he was alert and oriented x4, cranial nerves II-XII were intact , and on formal motor evaluation, he had 5/5 strength throughout all muscle groups of the upper and lower extremities.Imaging on presentationUpon arrival at the emergency department, a CT head without contrast demonstrated a hyperdense, well-circumscribed lesion in the right parietal lobe measuring 3.2 cm in length, 1.6 cm in width, and 3.2 cm in height with surrounding vasogenic edema Figure . A CT chTreatment and surgical resectionWe recommended a semi-urgent surgical resection. Our rationale for doing surgery on a semi-urgent basis was based on several key factors. First, the posterior aspect of the patient’s superior sagittal sinus was severely stenotic secondary to the mass effect of the tumor , specifically the following modalities: somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), and electromyography (EMG). The patient was positioned supine, head turned to the left, allowing for the right parietal lobe mass to be at the highest point of the operative field. A straight, linear incision perpendicular to the patient's SSS was made. Stealth navigation  was used to mark the boundaries of the tumor, and the craniotomy was performed. The dura was opened in a 'U' shape with the base tacked up and reflected over the SSS. We then proceeded with dissection. Immediately after penetrating the tumor capsule, a large, black-colored blood clot was encountered with surrounding yellow-tinged granular tissue. The tumor immediately started bleeding profusely and continued to do so until the last portion of the tumor was resected. Pathology came back as WHO grade-I meningioma, and histology sections are shown below in Figure Postoperative imaging A CT head without contrast was obtained immediately following surgery, demonstrating expected postoperative changes Figure . Twenty-Postoperative clinical courseThe patient tolerated surgery well without any changes in neuromonitoring. He was extubated immediately after surgery, and shortly after, he was back to his baseline neurological status. He was admitted to the ICU for neuromonitoring overnight. The next day (postop day one), he was downgraded out of the ICU. He worked with physical therapy (PT) and was ambulatory without assistance. On postop day two, PT recommended he return home to his prior living situation, and he was discharged from the hospital the following day (postop day three). When he left the hospital, he was back to functioning at his neurological baseline. At his third-month follow-up appointment, surveillance MRI showed no signs of tumor recurrence.Meningiomas are the most common primary brain tumor, accounting for approximately one-third of all primary brain tumors. Most are found incidentally on radiographic images obtained for other reasons. Patients are usually asymptomatic and can be managed conservatively with observation. However, if patients present with symptoms attributable to the meningioma or tumor growth seen on serial imaging, then surgical intervention is typically indicated .Spontaneous ITH primarily occurs in the setting of high-grade gliomas and metastatic brain tumors, but rarely with meningiomas. Intratumoral hemorrhage within meningiomas constitutes a mere 1.3% to 2.4% of all cases -9. When PresentationTypical presenting signs and symptoms of ITH in meningiomas include sudden onset of stroke-like symptoms, rapid onset of headache, nausea and vomiting, neurological disturbances, loss of consciousness, seizures, and coma ,11. HoweRisk factorsSuggested risk factors reported in the literature for meningiomas presenting in the form of spontaneous hemorrhage include age (>70 or <30), history of traumatic brain injury, antiplatelets or anticoagulant use, hypertension, serotonin modulating medications, and estrogen replacement hormone therapy ,14. IntePathophysiologyThe rarity of ITH in meningiomas could be attributed to the fact that they are typically slow-growing tumors with a rich fibrous matrix that potentially provides structural stability, reducing the chances of hemorrhage. Thus, the pathophysiology leading to hemorrhage in these cases remains unclear, although several theories have been suggested Table . Management strategies and prognosisEarly diagnosis of ITH meningiomas is crucial, as definitive surgical resection is associated with the best possible outcome, lowering the mortality rate from 55% to 13% ,16. FurtThis case highlights an unusual presentation of a parasagittal meningioma presenting as spontaneous ITH, a phenomenon infrequently reported in the literature. Key learning points include the following: surgical resection substantially lowers morbidity and mortality; without surgery, the re-hemorrhage rate is exceedingly high; and gross total resection (GTR) is the best method for obtaining hemostasis. We attribute the successful management of our patient to prompt surgical intervention. Although no specialty guidelines exist, we suggest prompt surgical resection be considered the standard of care.


Parastomal evisceration represents a preventable surgical complication that should not occur with appropriate technical diligence and surgical skills. While late parastomal hernias are well described in the literature, there is a paucity of reports on the early postoperative occurrence of parastomal intestinal evisceration.An urgent laparotomy was performed on a 58-year-old female patient for an acute cecal perforation with generalized peritonitis related to underlying colon cancer. Intraoperative revelations necessitated a carcinologic right colectomy and the creation of an end-loop ileocolostomy. Following six sessions of adjuvant chemotherapy, Computed tomography scans raised uncertainties about the presence of peritoneal carcinomatosis. Consequently, a collaborative decision was reached in a multidisciplinary discussion to conduct a surgical biopsy of these deposits before reinstating digestive continuity. The surgical procedure started with stoma mobilization. However, adhesions and a relatively confined aperture curtailed a comprehensive peritoneal cavity exploration. Thus, a midline incision was executed. The verdict from the frozen section examination affirmed metastatic presence, prompting the retention of the stoma. Within 48 h post-surgery, an early-stage parastomal evisceration occurred, stemming from an inadequately sealed aponeurotic sheath. The exposed bowel surface was encased in fibrin, necessitating meticulous irrigation with a warm saline solution before repositioning it within the peritoneal cavity. Accurate adjustment of the aponeurosis closure ensued, coupled with a meticulous reconstitution of the stoma. The postoperative course was uneventful. The patient was subsequently referred for hyperthermic intraperitoneal chemotherapy.Preventing parastomal evisceration requires adherence to established stoma-creation protocols, including creating a properly sized fascial opening and secure fixation. In instances of excessive fascial opening, ensuring a tension-free and meticulous closure is imperative. Parastomal evisceration represents a preventable surgical complication that should not occur with appropriate technical diligence and surgical skills . The potA 58-year-old female patient, known to have a medical history of type 2 diabetes and hypertension, was admitted to our surgical ward due to a perforated right colon tumor. She exhibited fever and tachycardia. Physical examination revealed a sizable mass, measuring 15 cm, and rebound tenderness in the right hemi abdomen. A digital rectal examination detected a painful bulging in the anterior wall of the rectum. In response to this critical condition, an emergency computed tomography (CT) scan was conducted. The results pointed towards a perforated cecal tumor along with two abscesses measuring 20 cm and 15 cm. These abscesses were located beneath the right diaphragmatic dome and within the Douglas pouch, respectively. There were no signs of metastatic spread observed. After a brief resuscitation, the patient underwent a median laparotomy. Initial assessment disclosed a generalized purulent peritonitis linked to the perforation of a 15 cm cecal tumor. Coexisting right subphrenic and Douglas abscesses were confined by the hepatic flexure and ileal loops, respectively. During the surgical procedure, the abscesses were appropriately drained, followed by a carcinologic right colectomy. Owing to the septic peritoneal environment, an end-loop ileocolostomy was created. Anatomopathological evaluation indicated a stage III colon cancer. The patient’s treatment plan extended to adjuvant chemotherapy. Subsequent evaluations through CT scans and abdominal magnetic resonance imaging revealed no evidence of liver metastasis but uncovered multiple cystic nodules dispersed throughout the peritoneal cavity. After multidisciplinary discussions, the decision was reached to proceed with a laparotomy, and frozen section examination of the cystic lesions prior to restoring digestive continuity. Notably, pre-surgery physical and radiological assessments did not reveal signs indicative of parastomal herniation.The patient underwent surgery one month after the last chemotherapy session. The surgical procedure started with stoma mobilization. However, adhesions and a relatively confined aperture curtailed a comprehensive peritoneal cavity exploration. Thus, a midline incision was executed. Intraoperative findings were indicative of carcinosis nodules dispersed throughout the peritoneal cavity, a conclusion corroborated by the frozen section report. To mitigate the risks of bowel obstruction and postoperative leakage, the decision was made to retain the double-barrel stoma. Within 48 h of the postoperative course, amid ongoing paralytic ileus, the patient reported abdominal pain and significant swelling at the stoma site. Upon assessment, it was revealed that approximately 1 m of the small bowel had eviscerated through the stoma location , or asthma. Moreover, the utilization of corticosteroids has also been identified as a pertinent risk factor . The medParastomal evisceration is a potentially life-threatening complication. Preventing this condition requires strict adherence to established stoma-creation protocols. An adequate fascial opening tailored to the stoma’s size, along with secure fixation, are pivotal stages in this process. In instances of excessive fascial opening, ensuring a tension-free and meticulous closure is imperative. Although prophylactic mesh placement may be considered to avert this complication, it is not advised in cases of peritoneal carcinomatosis with scheduled cytoreductive surgery. Instead, relaxation incisions should be implemented as a more suitable alternative.


Ambiguous genitalia is a matter of concern and needs thorough evaluation and treatment. Gonadectomy becomes a potentially lifesaving procedure in patients with partial androgen insensitivity due to the increased risk of malignancy if left undiagnosed.We present a case report of two patients in their late 20s and 30s, raised as girls, who came with complaints of primary amenorrhea with ambiguous genitalia. Both patients had features of masculinization. Her MRI revealed an absent uterus, cervix, upper 2/3 of the vagina, and ovaries, with the presence of bilateral testicles. She was diagnosed with partial androgen insensitivity syndrome. The first patient underwent bilateral gonadectomy with hernia repair and nerve-sparing reduction clitoroplasty with labioplasty. She is under close follow-up with a further plan for augmentation mammoplasty. The second patient, however, refused clitoroplasty and underwent bilateral gonadectomy.Androgen insensitivity syndrome is an X-linked inheritance with a mutation in the AR gene. It consists of a spectrum of conditions ranging from complete insensitivity to less insensitivity towards testosterone, which results in a complete, partial, and mild form of androgen insensitivity syndrome. Studies have been done on cosmetic outcomes after genitoplasty in children with genital atypicalities, which showed significant improvement (p<0.001) and no difference in ratings by parents and surgeons.Surgeries done on patients with partial androgen insensitivity syndrome are not only lifesaving procedures, but with reasonable reassurance, these aesthetic surgeries help people live a life that otherwise would have been genetically compromised. Living with a rare disease is itself a challenge and a continuing stigma in this present world. Ambiguous genitalia belongs to one such spectrum with a varied presentation, making its diagnosis difficult. It also stands as a therapeutic dilemma and a challenge to clinicians. It is a congenital condition caused by atypical development in chromosomal, gonadal, and phenotypic sex expression. External sex organs may differ from internal sex organs or genetic sex. It is a sexual development condition. Usually, ambiguous genitalia is visible at or shortly after birth, which can be quite upsetting for families. The sex organs of men and women develop from the same tissue. The presence or absence of male hormones determines whether this tissue develops into male or female organs. In a genetically male fetus, a lack or shortage of male hormones can result in ambiguous genitalia, whereas exposure to male hormones during development results in ambiguous genitalia in a genetically female fetus. Other reasons are genetic mutation, chromosomal abnormalities, and enzymatic deficiency. Family history may be a factor in the development of ambiguous genitalia because many sex development disorders are the result of inherited genetic anomalies.We present a case report of two patients raised as girls with features of masculinization, primary amenorrhea, and ambiguous genitalia.Case report 1A 20-year-old woman presented at our OBG Outpatient Department three months ago with complaints of primary amenorrhea and a lump palpable in the inguinal area. She was seventh in birth order and had no notable family background. Patients and family members had previously failed to seek medical guidance.2. She had a male-type body contour with hirsutism . Her breast tissues were not developed (Tanner’s stage 2), and axillary hair was present with pubic hair developed to Tanner’s stage 4. In the abdomen, bilateral lumps were palpable in the inguinal region. On local examination, there was clitoromegaly , and a urethral opening 1 cm below the clitoris was seen. Both labia majora and minora were well formed, with a blind vagina of 3 cm. Per-rectally, the uterus was not palpable.On examination, her height was 161 cm, her weight was 65 kg, and her BMI was 25.07 kg/mHer testosterone levels were high: 196.6 ng/dL . Her serum LH  and FSH  levels were elevated, but she had a low level of estradiol . However, the levels of dehydroepiandrosterone sulfate , androstenedione , 17-hydroxyprogesterone , and cortisol  were within the standard range.An MRI revealed that there was no uterus, cervix, upper 2/3rd vagina, or ovaries, but there were bilateral testicles with seminal vesicles, vas deference, and a little prostrate-like tissue at the bladder base. There were no numerical or structural irregularities in the karyotype, which was 46XY.Following detailed counselling, the patient underwent bilateral gonadectomy with hernia repair and nerve-sparing reduction clitoroplasty. Per-operatively, bilateral gonads were identified, and the total clitoral length was 9.5 cm. Histological examination showed Leydig cell proliferation and atrophic seminiferous tubules with no evidence of any ovarian tissue, hence confirming the gonads as testis. The diagnosis of partial androgen insensitivity was confirmed. Her post-operative stay was uneventful Figures -4.The repeat hormonal profile after a month showed testosterone level <10ng/dl. The patient was kept on hormonal therapy during her follow-up and planned for augmentation Mammoplasty eventually.Case report 2Another 32-year-old married nulligravida appeared in our outpatient department with a six-month history of bilateral inguinal area edoema and pain. She had no notable family history. The patient had primary amenorrhea but had failed to follow up.2. Tanner stage 4 breast development: axillary hair is present with pubic hair development (Tanner stage 4). On examination, there was bilateral firm tender swelling (6 cm × 4 cm and 4 cm × 4 cm) with a positive cough impulse. She had clitoromegaly of about 3 cm  with otherwise well-developed female external genitalia and an 8 cm blind vaginal pouch. Her ultrasound revealed non-existent ovaries, uterus, cervix, and testicular-like abnormalities in the inguinal region. Serum testosterone level was 178 ng/dL ; other hormone levels were within normal limits. The karyotype was 46XY, with no structural/numerical aberrations, confirming the diagnosis of partial androgen insensitivity. High cord ligation with bilateral orchiectomy was done with a refusal to further any cosmetic surgical intervention. Histopathological examination revealed a mixed germ cell testicular tumour  but resistant to male hormones  and thus has some of the physical attributes of a woman with the genetic composition of a man, with an incidence of one in 130,000 births [Bilateral 39%) or unilateral 28%) inguinal hernia, a positive family history (21%), a mismatch between amniocentesis-karyotype and phenotypic sex (6%), and primary amenorrhea (6%) are some of the clinical manifestations [8% inguin9% or uniSurgical and non-surgical aesthetic gynaecologic procedures have redefined the notion of beauty . Gender Individuals who live with a rare disease can face challenges that can be overwhelming. These challenges may include limited information about the disease and the treatment, adjustment to daily activities, social isolation, a wide range of emotions, and economic difficulties. A multidisciplinary team with a psychiatrist and a gynaecologist is required who could counsel about the condition and its prevalence, sexual identity, inability to have childbearing capacity, the need for surgery, regular postoperative follow-up, and hormone supplementation.LimitationsThe patients in the study were consenting adults when they underwent genitoplasty, thus eliminating the factor that makes these surgeries controversial for patients with differences in sex development (DSD): that they are almost always too young to consent to the surgeries that shape their bodies into conformity with the gender assigned at birth and the stereotypical sexualities associated with those genders.Surgeries done on patients with partial androgen insensitivity syndrome are not only lifesaving procedures but also help them live life on their own terms. It is a matter of great work and research, as gonadectomy after puberty is still controversial. Also, difficulties in determining the absolute malignancy risk, difficulties with hormone therapy, and a lack of studies supporting different protocols need attention and focus.


The omentum appears as an apron-like extension of the peritoneum.A 30-year-old male patient, presented to the emergency department with the chief complaints of acute nonradiating pain localized in the right-side abdomen for the past 3 days. The patient had a past medical history of sclerosing cholangitis (SC) with inflammatory bowel disease (IBD). The patient reported the pain as persistent, pressure-like, and moderate. The patient also had a low-grade fever and nausea at the time of admission. On examination, the vital signs were found as normal. The patient reported that the abdominal pain gets exacerbated after the meals, and increase in physical activity and movement. Due to the patient’s complaints and history of SC and IBD, these were considered as the possible diagnosis. After the diagnostic procedures, the patient was finally diagnosed with OT.This report presents a case of a patient suffering from omental torsion having history of SC and IBD. During the laparoscopic procedure, the diagnosis of omental torsion was confirmed. To our knowledge, no case report of omental torsion with IBD and SC is published in the literature.This seems to be a major diagnostic challenge as patients with IBD almost resembles the same clinical signs and symptoms as in the omental torsion. The possibility of misdiagnosis and delayed diagnosis could result in the unfavorable outcome. Therefore, the healthcare fraternities are advised to include the rare diseases such as OT as the differential diagnosis. Omental torsion is a rare condition characterized by acute pain in the abdomen. This condition can either be primary or secondary. This condition predominately affects males than females and more prevalent in adults. The exact etiology of the condition is unknown. However, it is associated with several risk factors such as obesity, cysts, hernias, and tumors. This condition can be managed conservatively with antibiotics, analgesics and anti-inflammatory agents. However, if the symptoms did not improve or the condition deteriorates (such as infarcted omentum) then definite treatment should be used. Laparotomy is performed as the definite treatment of OT and it involves resection of the torted or infarcted omentum. Clinically, patients with omental torsion presents with flank abdominal pain, frequently localized in the right-side of the abdomen, low-grade fever, nausea, and vomiting. OT mimics a number of other disease conditions such as acute appendicitis, cholecystitis, intestinal obstruction, and inflammatory bowel disease. These findings are nonspecific and can lead to misdiagnosis. The diagnosis of OT is generally made by ruling out the other disease conditions such as appendicitis and cholecystitis. The confirmatory diagnosis can be done abdominal ultrasound or CT scan. The nonspecific characteristics of condition, misdiagnosis, and delayed diagnosis pose the threat to patient’s health.HighlightsThe omentum appears as an apron-like extension of the peritoneum.The rotation on the long axis of the omentum is known as omental torsion.Ultrasonography or computed tomography scan remains a primary diagnostic tool.2. The rotation on the long axis of the omentum or twisting of omentum is known as OT. OT results in vascularity compromise on the distal parts of the omentum leading to tissue infarction and could result into infarcted omentum3.The omentum appears as an apron-like extension of the peritoneum, originating from the abdomen, and then descending towards the anterior part of the small intestine, further ascending and getting attached to the transverse colon8.OT occurs in a right-handed or clockwise direction where the venous blood return is affected resulting in congestion as well as edematous of the distal omentum. The etiology of OT is not exactly clear. There are various predisposing and precipitating factors reported for OT. Predisposing factors include the anatomical and vascular anamolies such as the expressions of tongue-like projections bifid omentum, abnormal vascular blood supply, trauma, obesity, and hyperperistalsis that further leads to variation in the weight of the omentum and displacement of the omentum. The precipitating factors includes cough, sudden movements or change in the posture of body like in the case of increased bowel motion, occupational hazards with vibrating tools and conditions that induce displacement in the omentum, elevated intra-abdominal strain, as a consequence of heavy exercise, sneezing, whooping, or excess straining9.The primary omental torsion (POT) is a mobile and thick omentum segment rotating on a fixed point proximally with no secondary intra-abdominal pathology. The various factors associated with variation in the anatomy of the primary omentum include tongue-like extensions projecting through the free edge, accessory omentum, bifid omentum, obesity resulting in the immoderate deposition of fat tissue inside the omentum, and a contracted omental pedicle. POT and secondary omental torsion (SOT) both presents similar clinical characteristics. The most typical symptom is a sudden onset of pain in the right iliac fossa in association with vomiting and nausea. When there is no underlying cause for the condition, it is known as POT. On the other hand, SOT is linked to other intra-abdominal pathologies such as omental cysts, adhesions, hernias, and tumors10. MRI can also be useful when OT is accompanied by complications such as the growth of an abscess or excessive bleeding.Ultrasonography or computed tomography (CT) scan remains a primary diagnostic tool as it helps for the diagnosis of OT avoiding the chances of misdiagnosis13.Laparoscopy is considered as a confirmatory tool for the diagnosis of OT. At laparoscopy, free serosanguineous fluid can be seen in the abdomenOmental torsion is usually misdiagnosed as it mimics a number of other conditions such as cholecystitis, acute appendicitis, intestinal obstruction, perforated duodenal ulcer, and abdominal wall hematoma. The diagnosis of omental torsion in patients with inflammatory bowel disease (IBD) and PSC remains a major challenge as all these clinical conditions present the common symptoms such as abdominal pain, low-grade fever, nausea, and vomiting that are nonspecific to the condition. Hence, this condition can be misdiagnosed as acute appendicitis, IBD and cholecystitis, which may results in the unfavorable outcomes.A 30-year-old male patient, presented to the emergency department with the chief complaint of acute nonradiating pain localized in the right-side abdomen for the past 3 days. The patient had a past medical history of sclerosing cholangitis (SC) with IBD. The patient reported the pain as persistent, pressure-like, and moderate. The patient also had a low-grade fever and nausea at the time of admission. On examination, the vital signs were found as normal. The patient reported that the abdominal pain gets exacerbated after the meals, and increase in physical activity and movement.14. However, the test indicated a normal appendix with no strands. The test also revealed the appearance of thickened fat tissues, oval in structure along with twisting of blood vessels in the right abdomen  criteria. The patient provided permission for the case to be published for scholarly and research purposes.Ultrasonography, CT scan, laparoscopy and MRI can be used for the diagnosis of OT. Once diagnosed, initially the condition can be managed conservatively with antibiotics, analgesics, and anti-inflammatory agents. However, if the symptoms did not improve or the condition deteriorates (such as infarcted omentum) then a definite treatment should be used. Laparotomy can be performed as the definite treatment of OT and it involves resection of the torted or infarcted omentum. The benefits of laparoscopy involve a detailed evaluation of the abdomen for confirming the diagnosis, as well as the advantages of minimal-access surgery, such as the reduction of postoperative pain as well as wound-related complications. The conservative management of OT is the rational alternative to surgery for hemodynamically stable patientsThis report presents a case of a patient suffering from omental torsion having history of SC and IBD. Omental torsion is a rare phenomenon that is often misdiagnosed with acute appendicitis and cholecystitis. Omental torsion is frequently misdiagnosed because it resembles cholecystitis, acute appendicitis, intestinal blockage, ruptured duodenal ulcer, and abdominal wall hemorrhage. The diagnosis of omental torsion in patients with IBD and PSC remains difficult since all of these clinical disorders present with nonspecific symptoms such as stomach discomfort, low-grade fever, nausea, and vomiting. As a result, this condition may be misinterpreted as acute appendicitis, IBD, or cholecystitis, leading to the unfavorable outcomes. Therefore, the healthcare fraternities are advised to include the rare diseases such as OT as the differential diagnosis.This case report has been reported in line with the SCARE criteria.Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.None.N.M., S.H.C., P.K., R.K., R.S., H.C.: conceptualization, data curation, writing – original draft preparation, writing – reviewing and editing; T.B.E.: conceptualization, writing – reviewing and editing, visualization.The authors declare that they have no financial conflict of interest with regard to the content of this report.Name of the registry: not applicable.Unique Identifying number or registration ID: not applicable.Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable.Talha Bin Emran.All data available in this manuscript.Not commissioned, externally peer-reviewed.