About 2% of all lung malignancies are pulmonary carcinoid tumors, a family of neuroendocrine tumors. Rarely does a typical tracheal carcinoid of the trachea manifest as an endoluminal polypoidal tumor.The author describe a 61-year-old nonsmoker who complained of growing nonexertional shortness of breath 5 years ago. She also had a wheezy chest and a dry cough. The results of the chest radiography and electrocardiogram revealed no noteworthy abnormalities. The results of the pulmonary function test supported the diagnosis of bronchial asthma. A patient’s treatment has not advanced. After performing a bronchoscopy, a biopsy was taken and sent for pathological analysis. The endobronchial lining was found to have a subepithelial tumor infiltrate made up of nests of homogeneous bland cells with central nuclei and mild granular cytoplasm, according to histopathologic analysis. Considering all of these findings, the patient was diagnosed with a primary tracheal carcinoid tumor, which was misdiagnosed and treated as bronchial asthma.People with stridor or trepopnea symptoms should undergo a computed tomography scan since central airway tumors can mimic the symptoms of bronchial asthma while a chest radiograph may be normal. Tracheal carcinoid that has not progressed to the mediastinum can be successfully removed with flexible bronchoscopy and electrocautery, but the excision site needs to be continuously watched for recurrence. HighlightsThe respiratory system’s endobronchial benign tumors are uncommon.Primary tracheal tumors are rare neoplasms that are difficult to detect on chest radiographs and have few symptoms, making them easy to miss.Since central airway tumors can mimic bronchial asthma symptoms and a chest radiography may be normal, individuals who exhibit stridor or trepopnea symptoms should have a further investigation, including a computed tomography scan and bronchoscopy.The respiratory system’s endobronchial benign tumors are uncommonOur patient is a 61-year-old nonsmoker female who was referred to us by a neighboring hospital. According to the patient’s medical records, she was admitted to the peripheral hospital 5 years ago for a complaint of progressive nonexertional shortness of breath associated with a wheezy chest and a dry cough. Electrocardiography and a chest radiography revealed unremarkable pathologies. The findings of the pulmonary function test were consistent with bronchial asthma . As a result, the patient was prescribed asthma medications and sent home.After 1 year, the patient was referred to our hospital due to the worsening of the same symptoms without any significant improvement in her clinical condition, despite her bronchial asthma treatment regimen. The patient noticed a loss of weight of ~3 kg over the past 2 months, which was not associated with a decreased appetite. She denied any chest pain or discomfort, fever, chills, hemoptysis, difficulty swallowing, or regurgitation of food. Past medical history is unremarkable except for controlled mild hypertension. The patient reported no personal and/or family history of cancer; any acute, repeat, or discontinued medications; any allergies; any chronic or autoinflammatory diseases; any genetic or psychosocial issues; and a free past surgical history.Upon admission, physical assessment revealed a mildly tachypneic patient with diffuse bilateral wheezing and expiratory stridor. Cardiac and abdominal examinations were noncontributory. Vital signs, electrocardiography, and laboratory evaluation, including a complete blood count and arterial blood gases, were normal. An radiography of the chest revealed a narrowing of the trachea about 2–3 cm above the carina Fig. . A compuKulchitsky cells that are dispersed throughout the bronchopulmonary mucosa give birth to carcinoidset al.’s18F-FDG PET/CT scan has low sensitivity and specificity in separating the pulmonary carcinoids from other tumors, the 68Ga-DOTATOC PET/CT is an effective imaging investigation for the evaluation of pulmonary carcinoids with a sensitivity of 96% and 100% specificityNinety percent of carcinoid lung neoplasms are typical carcinoid tumors, which primarily affect people under 40. Metastases to lymph nodes (5–15%) and distant locations (3%) are infrequent at presentation in patients with typical carcinoid tumors. Atypical carcinoids are less common than lung tumors (0.1–0.2%), but at the time of presentation, they frequently have distant (20%) or lymph node (40–50%) metastasesWhen circumscribed, carcinoid tumors are generally managed surgically. For normal and atypical carcinoid tumors, respectively, the 5-year survival rate following surgical excision is 97 and 78%Endobronchial tumor removal with bronchoscopy is a practical and effective methodSince central airway tumors can mimic bronchial asthma symptoms and a chest radiography may be normal, individuals who exhibit stridor or trepopnea symptoms should have a CT scan performed. Flexible bronchoscopy and electrocautery can be used to successfully remove tracheal carcinoid that has not spread to the mediastinum, but the excision site needs to be closely monitored for recurrence.Our institution has exempted this study from ethical review.A written informed consent for the data and picture was taken from the patient and the family and available upon request from the Editor-in-Chief.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.O.N.S., A.W.M.J., S.J., and A.K.: writing the manuscript.B.S.S. and I.A.B.: imaging description. O.N.S. and Y.A.A.: reviewing and editing the manuscript.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.None.Oadi N. Shrateh.Not commissioned, externally peer-reviewed.All authors attest that they meet the current ICMJE criteria for authorship.


Polymorphous low-grade neuroepithelial tumor of the young (PLNTY) is a low-grade epilepsy-associated tumor recently introduced in WHO 2021 classification. Since it has been recognized as an independent nosological entity, PLNTY has been mainly studied from a genetic and molecular perspective, not recognizing unique characteristic clinical and radiological features.A systematic literature research has been conducted aiming to identify all relevant studies about the radiological, clinical and surgical features of PLNTY. We described a representative case of a 45-year-old man treated with awake-surgery with confirmed diagnosis of PLNTY, reporting the radiological and surgical characteristics through imaging and intra-operative video. We performed a statistical meta-analysis attempting to assess the presence of relationships between surgical and radiologic tumor characteristics and clinical outcome and type of surgery.p = 1), the presence of cystic intralesional component, calcification (p = 0.85), contrast-enhancing and lesion boundaries (p = 0.82). No significant correlation there is between EOR and remission or better control of epilepsy-related symptoms (p = 0.38). The contrast enhancement in the tumor is significantly associated with recurrence or poor control of epileptic symptoms (p = 0.07).A total of 16 studies were included in the systematic review. The final cohort was composed of 51 patients. Extent of resection (EOR) and outcome are not significantly associated with the different genetic profiling (In PLNTYs, contrast enhancement seems to impact prognosis, recurrence, and seizure control much more than radiological features, genetic features and type of resection of the tumor.The online version contains supplementary material available at 10.1007/s13760-023-02231-z. Polymorphous low-grade neuroepithelial tumor of the young (PLNTY) is a low-grade tumor comprised of infiltrating “oligodendrocyte-like” cells  that staRadiologically, clinically and surgically still, very little is known about this rare tumor. The diagnostic challenge most often involves distinguishing this tumor from an oligodendroglioma, given, especially in adults, the morphologic and clinical overlap and the potential for misdiagnosis are significant . BecausePLNTYs, indeed, can be morphologically highly variable, manifesting as well-circumscribed lesions, cystic lesions, or infiltrative growth patterns. The constant element appears to be the calcific component that is always present in the context of the lesion, leading it to be in differential diagnosis with oligodendroglioma . In thisAn extensive systematic search has been conducted on Pubmed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, to identify all potentially relevant studies about the radiological, clinical, and surgical characteristics of PLNTY reported. In searching for relevant studies, the reference section of included articles was analyzed. The search was performed by typing the following items: “Polymorphous low-grade neuroepithelial tumor of the young AND/OR PLNTY.”The first selection step was describing the clinical entity of PLNTY in pediatric and adult patients and its characteristics.In this regard, we chose to evaluate only the studies focused on PLNTY only PLNTY-focused studies and papers that described patients or series reported and described clinically and radiologically.Availability of full-text articles;English text only;Patients with a diagnosis of PLNTY;Reported details on imaging;Presence of neurological outcome evaluation. No specific limitation was applied regarding the timing of neurological evaluation after treatment.Given these premises, we selected papers according to the following inclusion criteria:Full-text articles in languages other than English;Studies reporting patients with the low-grade tumors;No data available about the neurological outcome;No imaging details were reported;Conversely, exclusion criteria were:Data extracted from each study were (1) authors, (2) year of publication, (3) number of patients included, (4) age, (5) sex, (6) clinical debut and presentation on diagnosis, (7) side involved, (8) major cerebral lobe involved, (9) imaging characteristics, (10) presence of contrast-enhancing in magnetic resonance imaging (MRI) studies, (11) major diameter of tumor in MRI studies, (12) characteristics of radiological limits of the lesion , (13) mutation identified on diagnostic molecular analysis, (14) surgical treatment indicating the extent or resection (EOR), (15) clinical and neurological outcome after treatment.We added and described a representative case from our experience reporting the radiological and surgical characteristics through imaging and intra-operative video. From the available data, we performed a statistical meta-analysis attempting to assess the presence of significant relationships between surgical and radiologic tumor characteristics and clinical outcome and type of surgery.® Purely Navigation), in a standard neurosurgical theatre, with a standard operative microscope . In the first postoperative day, as routine, the patients underwent volumetric Brain MRI scan to evaluate the EOR.A 45-year-old right-handed man without relevant clinical history presented to our institution for partial seizure in left hand. In addition, He reported approximately two recent episodes of extreme fatigue in which he would fall asleep and be unarousable for hours, as well as shorter duration facial and arm paresthesias. The patient was admitted for neurological care and underwent neuroimaging to rule out a structural cause for his symptoms. The patient underwent a preoperative brain MRI scan included a high-field 3 Tesla volumetric study with the following sequences: T2w, FLAIR, isotropic volumetric T1-weighted magnetization-prepared rapid acquisition gradient echo (MPRAGE) before and after intravenous administration of paramagnetic contrast agent; diffusion tensor sequences (DTI) with 3D tractography and functional MRI (fMRI). The procedure was performed with an infrared-based Neuronavigator  ratio. Initial imaging raised concern for an oligodendroglioma, though location and dense central calcifications were thought to be atypical.An initial non-contrast head CT showed a partially calcified intra-axial mass in the right temporoparietal lobe. MR imaging confirmed the presence of the lesion in the peritrigonal area involving the corpus callosum and internal capsule, which demonstrated a heterogeneous signal with few intralesional calcifications. Faint T1 hyperintensity was seen within the tumor, while other regions demonstrated minimal enhancement. Focal regions of elevated relative CBV were noted within the tumor on DSC perfusion imaging. A mild associated mass effect was seen, with effacement of the adjacent right lateral ventricle and expansion of an overlying right temporal lobe gyrus, DTI show just a minimal displacement of with fibers involving the right arcuate fasciculus. However, there was no midline shift or herniation. Preoperative imaging was completed on a 3T MR imaging scanner to optimize fMRI and spectroscopy. On this examination, the signal with multivoxel did not show significant spikes or reversal of the choline/Preoperative language fMRI was predominantly used to establish the patient’s hemispheric language dominance and the dislocation of the primary motor area; because the tumor location and posterior corpus callosum involvement would have necessitated an awake resection with electrocortical stimulation mapping to prevent a postoperative motor and coordination deficit. The patient performed fMRI language tasks in the scanner. The derived statistical maps demonstrated left-hemispheric language dominance Fig. .Fig. 1ThThe patient underwent resection of the mass via a right temporoparietal craniotomy. The surgeons elected to approach the tumor through a corticectomy of the right superior parietal lobule, the shortest route to the tumor given the reassuring fMRI data. Intraoperative evaluation of the tumor demonstrated a high variable lesion in consistency, aspect, and coloration (Video 1). The tumor was just partially removed in a piecemeal fashion. The debulking was stopped in case of speech or motor arrest of patients. In the postoperative phase, the patient manifested hemiparesis in the left arm and recovered over the next 2 weeks after the procedure. No manifestations of tactile sensory alterations, stereoagnostic disturbances, or visuospatial localization have been reported.The patient did well postoperatively without immediate complications. Histological diagnosis confirmed the presence of PLNTY (grade I WHO) with ki-67 = 3% and BRAF-V600E mutation.p < 0.05.The sample was analyzed with SPSS version 18 . A comparison between nominal variables was made with the chi-square test. Means of continuous variables were compared with one-way and multivariate analysis of variance along with contrast analysis and post hoc tests. Continuous variable correlations were investigated with Pearson bivariate correlation. The threshold of statistical significance was considered at A total of 28 studies were found through PubMed database search and reference section screening. An automatic tool working on Microsoft Excel spreadsheets carried out a duplicate check. Out of 28 initial papers, one duplicate and 2 paper with another language other than English were removed; thus 25 potentially articles were identified, and, following the eligibility criteria, 20 papers were screened. In particular, manuscripts did not fulfilling the eligibility criteria, because they were out of topic , not focusing on clinical characteristics , and four papers were excluded for insufficient detail of case analysis and finding (four papers). A total of 16 articles were included in the systematic review. Out of 50 patients overall included, 1 patient was successfully added to the analysis from our institutional experience. The selection flowchart diagram is reported in Fig. The final cohort was composed of 51 patients. The average age of the patients was 22.16 years , with a slight predominance of male sex (54.9% versus 45%). The main symptom of the onset is seizure comprehensive of a single seizure attack  and intractable epilepsy . Other symptoms at onset reported are headache , visual disturbance , and mood disorder .Regarding the genetic profile, the most expressed mutation is BRAF V600 (23 pts—47.9%) followed by FGFR2 alterations (9 pts—18.8%), FGFR3-TACC3 (5 pts—10.4%), KIAA1598-FGFR2 fusion (4 pts—8.33%), NTRK2 disruption (1 patient—2.1%), although 6 patients do not present a specific alteration (6 pts—12.5%). We analyzed the reported radiological features of cystic intralesional component, calcification and contrast-enhancing and data available about the choice of treatment and clinical outcome. None of the reported cases described the features the tumor took on about the eloquent areas and white matter bundles identifiable on tractography examinations. All the relevant details are included in Table p = 0.85, lesion boundaries (blurred or circumscribed) with EOR, p = 0.82).The descriptive analysis of the literature shows how important EOR is in treating PLTNY. We analyzed the main clinical and radiological factors that may result in gross total resection of the tumor. We did not identify any significant variables regarding the achievement of complete resection of the tumor. In particular, we analyzed how radiologic features could impact the different types of surgical treatment selected in terms of EOR. Analyzing the presence of cystis, calcification, and lesion boundaries (blurred or circumscribed), we did not find any statistically significant correlation  versus the peak incidence between 40 and 60 years, which is more descriptive of oligodendroglioma Both neoplasms can be incidentally found, but otherwise, patients are most likely to complain of new seizures with the epileptogenic mass . The disExamining the outcomes of the few surgically treated patients diagnosed with PLNTY shows that the outcome is not always optimal. Indeed, even though a GTR or lobectomy occurs, the patient does not have complete control of seizures and that despite a typical genetic expression, they do not correlate with a particular outcome. Cases of recurrence or biological shift to more aggressive forms of glioma have also been identified . In thisPLNTY is notable for the presence of oligodendroglioma-like cellular components and CD34 immunopositivity. Immunohistochemical markers such as CD34 are other valuable tools that can readily discriminate between PLNTY and oligodendroglioma since the last staining negatively while PLNTY stains positively. Molecular analysis has identified frequent genetic abnormalities involving the B-Raf proto-oncogene (BRAF), fibroblast growth receptor (FGFR), and a distinct methylation pattern. PLNTY has been found to have a different DNA methylation signature , like BRThe clinical significance of CD34 expression and BRAF mutation was investigated in a recent publication aiming to study the relationship between biomolecular markers and clinical–pathological features . The stuAlthough the BRAF V600E genetic mutant may play a causative role in PLNTY’s growth and may be promising to pursue new medical therapy for PLNTY , no assoThe most extensive published series of PLNTYs described by Huse et al.  showed iFew PLNTY cases of the following reported articles yield insufficient knowledge of radiology to apply to the diagnostic setting. The only specific radiological study published by Chen et al.  demonstrThe calcifications seen on MRI are also apparent in the histopathology of both tumors, and the general cell morphology of PLNTY mimics oligodendroglioma closely .What is reported, however, is that in most cases, PLNTY presents as a well-circumscribed tumor , 17 thatWhile all reported cases are shown as hyperintensity in T2WI and iso- or hypointensity in T1WI with slight or no enhancement after contrast-enhanced, in some cases, PLNTY tends to prominently show an infiltrative growth pattern with adjacent tissue involvement and subpial extension and partly exhibit sharp borderline , 18. In To better understand the characteristics of the tumor with a view to suboptimal surgical resection in our representative case, we evaluated DTI and spectroscopy values in suspicion of an early malignancy form. We identified that within a multi-voxel study, only in a deep peri-callosal portion of the tumor a mild and unremarkable choline peak was expressed compared to NAA Fig. . The DTIThe significant radiological variability present in the imaging of PLTNY does not only affect the different cases reported in the literature –20; in fFurther investigation will be necessary to define the clinical implications of the imaging observations described herein. In particular, it will be important to re-evaluate contrast-enhancement rates in other intra-axial pediatric and young adult brain tumors as current pathologic criteria define those entities.PLNTYs exhibit an almost invariably benign clinical course and appear well controlled by surgical resection. The prototypical PLNTY is a well-circumscribed lesion with macroscopic calcification and a cystic component located peripherally within the posteroinferior temporal lobe of a young patient. Still, from our recent analysis, its radiological and clinical variability appears to be much wider. Surgically, excision can be burdened by profound tumor variability and difficulty identifying tumor margins. The molecular driving alterations, such as BRAF V600E and FGFR translocations, do not predict the post-surgical outcome. On the radiological aspect, in PLNTY, contrast enhancement seems to impact prognosis, recurrence, and seizure control much more than radiological features of the tumor.Supplementary Video 1: The video shows highlights of the surgical procedure performed in awake. After a right parietal craniotomy under neuronavigation guidance, the area of signal alteration visible on MRI was reached. Note the different moments, during intra-lesional debulking, when the change in tumor texture and color was witnessed. (MP4 30324 KB)Below is the link to the electronic supplementary material.


The rate of residual liver recurrence after the resection of colorectal liver metastases is high, and most cases recur within 5 years of the initial hepatectomy. Here, we report two cases of residual liver recurrence after radical resection of colorectal liver metastases after a long recurrence-free survival period.Case 1 involved a 62-year-old woman treated for ascending colon cancer in April 2011 who underwent right hepatectomy for synchronous colorectal liver metastasis in April 2012. However, in September 2021, computed tomography revealed residual recurrence in the lateral segment of the liver, and a lateral segmentectomy of the liver was performed. In Case 2, a 52-year-old man treated for cecal cancer in July 2002 underwent lateral segmentectomy of the liver for metachronous colorectal liver metastasis in October 2006. Subsequently, there was no recurrence; however, computed tomography showed residual liver recurrence in the right lobe of the liver in October 2021, and an expanded posterior hepatic segmentectomy was performed.Histopathological findings in both cases were consistent with colorectal liver metastases.We encountered two cases in which residual liver recurrence was observed after a long period of recurrence-free survival. Although rare, there have been a few cases of late recurrence of liver metastases after radical resection of cancer liver metastases. Colorectal liver metastasis (CRLM) is the most common site of recurrence after radical resection of colorectal cancer. The best treatment for the first CRLM is hepatectomy, and the 5-year survival rate is reported to be 35–58% . FurtherResidual liver recurrence after CRLM surgery often occurs within 5 years .In this study, we report two cases of residual liver recurrence following CRLM resection with a long period of recurrence-free survival.2 and LV at a dose of 75 mg/body on days 1–28, every 35 days for five courses) as adjuvant chemotherapy.A 62-year-old woman with no particular medical history was diagnosed with ascending colon cancer and referred to our hospital. Her blood test results were as follows; carbohydrate antigen 19–9 (CA19-9), 48.3 U/mL (< 37.0); and carcinoembryonic antigen (CEA), 11.4 ng/mL (< 5.0). She underwent laparoscopic-assisted right hemicolectomy (D3 dissection) in April 2011. Although a hepatic mass was observed preoperatively, only colectomy was performed because a definitive diagnosis of metastasis could not be made. Histopathological findings revealed that T4aN1 was a well-differentiated adenocarcinoma. She received oral uracil and tegafur plus leucovorin (UFT/LV) therapy  showed a tumor lesion with irregular margins and low density in liver segments 5 and 8. We determined that the hepatic tumor was a synchronous liver metastasis, and a right hepatectomy was performed after portal vein embolization. Four CRLM lesions were noted in the excised right liver lobe. The pathological stage was T4aN1M1a stage IVA, according to the eighth edition of the TNM classification of the American Joint Committee on Cancer (AJCC) for International Cancer Control (UICC).2 and oxaliplatin at a dose of 120 mg/m2 on day 1 of a 21-day cycle) as adjuvant chemotherapy. She has been recurrence-free for a long time and discontinued regular hospital visits in March 2019.She received six courses of combination therapy with capecitabine plus oxaliplatin  was initiated. However, we could not determine whether the lesion was a late-onset CRLM recurrence or a new lesion, such as an intrahepatic cholangiocarcinoma; therefore, a liver biopsy was performed.2, respectively) plus bevacizumab four times every 2 weeks, and combination therapy with 5‐fluorouracil, levofolinate, and irinotecan (FOLFIRI) plus bevacizumab twice and FOLFIRI once. After NAC, the liver metastasis did not shrink; however, necrosis was observed  7, CK20, and caudal-type homeobox transcription factor (CDX)2 were positive on immunohistochemical staining. Since it was similar to the primary tumor, we diagnosed it as late-onset CRLM. She was treated with triplet chemotherapy with fluorouracil/folinic acid, oxaliplatin, and irinotecan  with low density in the central part and a faint ring-enhancement effect in S7/8 of the liver. .Based on these imaging findings, he was diagnosed with metachronous CRLM. As the tumor had invaded the root of the 8 dorsal branch, we decided to perform NAC to reduce the resection area. The patient received three courses of combination therapy with capecitabine and oxaliplatin (XELOX)  as adjuvant chemotherapy for 6 months. He has been recurrence-free for 14 months since the last surgery. We have summarized the clinical course of Case 2 in Fig. No postoperative complications were observed, and he was discharged on the eighth postoperative day. After resection of the CRLM, he received UFT/LV therapy  [. reported that the interval between the first and second surgeries in patients undergoing hepatectomy was reported to average 20 months, and approximately 30% of patients underwent a second surgery within 1 year [After resection of CRLM, 50–70% of patients develop recurrent CRLM again . Subsequ months) . Metcalfn 1 year . Howevern 1 year .We investigated cases of residual liver recurrence in patients who underwent initial resection for CRLM at our hospital for 10 years from 2006 and 2015. A total of 62 cases of residual liver recurrence were found, of which 60 cases recurred within 5 years, excluding the two cases (3.2%) in this study. The two cases recurred 9 and 15 years after resection of the primary CRLM. Table Not limited to CRLM, patients in the late-recurrence group had lower preoperative CEA levels. In addition, tumors with expanding growth, well-differentiated histological types, and a lack of lymph node metastasis were more common in the late recurrence group . Cho et . and many others reported that there was no significant difference in morbidity and operative mortality rates after re-hepatectomy compared to initial hepatectomy [Re-hepatectomy is generally a highly difficult operation because of adhesions, anatomical displacement, and changes in the liver parenchyma caused by chemotherapy. However, Wurster et alatectomy .In Case 1, the patient discontinued regular hospital visits, which delayed the discovery of the second CRLM. In Case 2, the second CRLM was found during a physical examination.Even after surgery for CRLM, recurrence of the residual liver may occur in the late stage; therefore, follow-up should be considered even 5 years after surgery, especially in cases of younger patients with well-differentiated tumors.In this study, we encountered two cases in which residual liver recurrence was observed after a long recurrence-free survival period following radical resection of CRLM.In patients who have undergone resection of CRLM, it is desirable to encourage them to undergo medical examinations even after completion of follow-up observation and to strive for early detection of residual liver recurrence.The first operation in Case 2 was performed approximately 20 years ago, and the photographic data of the pathological specimen had already disappeared.


Primary T-cell non-Hodgkin lymphoma (NHL) of the gastrointestinal tract (GIT) is a rare, poorly-characterized clinical entity. A well-known complication of intestinal NHL is perforation due to chemotherapy, but perforation as a presenting sign of GIT lymphoma is extremely rare. Here we present a case of spontaneous intestinal perforation secondary to primary intestinal T-cell lymphoma and highlight the importance of early recognition of this uncommon cause of perforation as a crucial step to ensure expedited hematology referral and initiation of appropriate treatment. Primary small bowel neoplasms are incredibly rare, comprising approximately 1-5% of all gastrointestinal cancers in the United States . LymphomThis article was previously presented as a meeting abstract at the 2021 American College of Gastroenterology Annual Meeting on October 25, 2021.A 56-year-old man presented with acute severe abdominal pain and nausea. On arrival, he was hypotensive and tachycardic. His abdomen was rigid and diffusely tender. Labs were notable for leukocytosis, lactic acidosis, and venous pH of 7.2. Abdominal computed tomography (CT) demonstrated moderate pneumoperitoneum and high-grade small bowel obstruction without an identifiable transition point, as seen in Figure Intraoperatively, a 3 mm perforation within an inflamed segment of the proximal ileum was found, which was biopsied and sutured closed. Our patient underwent diverting loop ileostomy proximal to the site of inflamed ileum and perforation and was admitted to the intensive care unit (ICU) for postoperative management. Peritoneal culture was positive for E. coli. A biopsy of the perforation showed mucosal denudation, gland dropout, ulceration, and marked acute and chronic inflammation Figure .The postoperative course was complicated by severe protein-calorie malnutrition requiring total parenteral nutrition (TPN) and high ileostomy output. Ileoscopy prior to discharge revealed scalloped mucosa and blunted villi up to 30cm proximal to the stoma and a single hemi-circumferential 5mm ulcer as seen in Figure Subsequent T-cell receptor rearrangement studies were positive for a clonal T-cell population, confirming the diagnosis of intestinal T-cell lymphoma. Staging CT was negative for metastatic disease, and bone marrow biopsy and peripheral smear were unremarkable. Our patient was ultimately referred to hematology for initiation of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. After two cycles of CHOP chemotherapy, our patient had marked improvement in ostomy output; however, our patient was briefly lost to follow-up and ultimately declined to pursue additional treatment of his cancer. After foregoing additional cycles of chemotherapy, his ostomy output increased, and after a brief admission for hypovolemic shock, he was initiated on TPN and discharged to a long-term acute care hospital for the ongoing care of his high-output ostomy.Although the GIT is the most common site of extranodal involvement of NHL, primary NHL of the GIT is extremely rare, comprising less than 4% of all primary GIT neoplasms . IntestiEarly recognition of primary intestinal T-cell NHL is challenging, largely due to its rarity and non-specific range of presenting symptoms: fever, abdominal pain, diarrhea, and GI bleeding -10. TherTreatment of primary intestinal NHL is multimodal, most commonly comprising surgery and CHOP chemotherapy. The same treatment approach is applied to both T-cell and B-cell primary intestinal NHL, though patients with T-cell involvement carry a worse prognosis . While iThis case report recognizes spontaneous perforation with peritonitis as a potential presenting sign of primary intestinal T-cell NHL. The diagnosis of NHL strictly relies on histopathologic analysis; thus, in patients with spontaneous perforation of unknown etiology, it is crucial to obtain intraoperative biopsies of the perforation and perform an endoscopic evaluation of intestinal mucosa after surgical recovery to evaluate for suspicious lesions. Given the rarity of this subtype of lymphoma, early recognition of this uncommon cause of perforation is essential to ensure expedited hematology referral and initiation of appropriate treatment.


Gallstones causing bowel obstruction, known as gallstone ileus, are rare and account for less than 0.5% of small bowel obstruction cases. Additionally, it is a rare complication affecting only 0.3% of patients who have gallstones.Fistula formation between the biliary system, most commonly between the gallbladder and duodenum because of their proximity, facilitates the migration of gallstones into the enteric system with subsequent impaction in the small intestine, usually in the distal ileum close to the ileocecal valve, promoting the development of mechanical small bowel obstruction.Computerized tomography of the abdomen and pelvis is a confirmatory and widely used imaging study when there are two signs of Rigler’s triad, which includes pneumobilia, evidence of small bowel obstruction and the presence of radiopaque stones.We report a case of a 75-year-old Caucasian man who presented with abdominal distention with signs of severe dehydration secondary to intractable nausea and vomiting complicated with severe acute kidney injury and was found to have a 4.7-centimeter gallstone-induced small intestinal obstruction. Bowel obstruction means impaired flow of the intestinal contents, and it develops secondary to either extraluminal or luminal pathology. Gallstones causing bowel obstruction, known as gallstone ileus, are rare and account for less than 0.5% of mechanical small bowel obstruction (SBO) cases . AdditioA 75-year-old Caucasian man with a past medical history significant for gastroesophageal reflux disease and essential hypertension was hospitalized for a two-day history of abdominal discomfort with associated intractable nausea; non-bloody, bilious vomiting; and generalized weakness.His symptoms were continuous, and he was unable to tolerate oral intake. Another pertinent history includes tonsillectomy but no abdominal surgeries. He was hypotensive (blood pressure 74/54 mm hg) and tachycardic at presentation, responded to fluid resuscitation, and became normotensive.His physical exam was notable for generalized distress and dry mucous membranes with diminished skin turgor. The abdomen was distended and diffusely tender but soft, with high-pitched, tinkling bowel sounds heard over the lower abdominal quadrants.His complete blood count was significant for leukocytosis and hemoconcentration, as shown in the table. His biochemical profile was significant for mild hyponatremia, hypokalemia, and severe prerenal azotemia as shown in the table and liver function tests and serum lipase levels were within normal limits.X-ray of the abdomen Figure  showed dComputed tomography (CT) of the abdomen and pelvis without contrast showed Figures -4 dilateFigure The patient was aggressively treated with nasogastric suction and fluid resuscitation. The patient underwent laparotomy, and the gallstone was easily identified and milked proximally. We found no other stones proximal to this stone. A vertical incision along the small bowel allowed for the removal of a large, dark green-colored gallstone measuring 4.7 cm × 3.0 cm × 2.5 cm Figure , and theSmall bowel obstruction secondary to gallstone ileus accounts for less than 0.5% of cases . IntrapeFistula formation is an important process for the facilitation of gallstone migration into the enteric system. Chronic inflammation of the gallbladder causes adhesiveness between it and the duodenum; over a period, stone pressure causes necrosis of the gallbladder wall, resulting in fistula formation, which is most commonly cholecystoduodenal because of the duodenal proximity to the gallbladder. Cholecystocolonic and cholecystogastric are other possibilities . Stone mThe biochemical profile is nonspecific, and imaging studies are diagnostic. X-ray abdomen upright shows classic findings, including dilated loops of the small bowel with air-fluid levels, pneumobilia (air in the biliary tree), and a radiopaque gallstone in the right iliac fossa, called Rigler’s triad. To confirm the diagnosis, the patient needs contrast-enhanced CT of the abdomen and pelvis, which is a widely used imaging study and needs to have at least two of the three signs of the Rigler’s triad. Pneumobilia is not a signature sign of gallstone ileus; it can be seen after endoscopic biliary procedures involving sphincterotomy, sphincter of Oddi dysfunction, and postoperatively in cholecystectomy patients. Lassandro et al. evaluated various imaging studies in 27 gallstone bowel obstruction patients in a retrospective study comparing abdominal X-ray, abdominal ultrasound, and contrast-enhanced CT of the abdomen and pelvis. CT has the highest sensitivity for confirming signs of bowel obstruction at 96.3%, followed by pneumobilia at 88.9% and gallstones at 81.8% [The risk of bowel obstruction lies in the size of the stone. El-Amin et al. studied patients with double contrast barium enema examination and colonoscopy and showed that the mean ileocecal valve height was 1.7 cm and the mean width was 2.8 cm . StudiesThe first step in the management of gallstone ileus is fluid resuscitation and relieving the intestinal obstruction surgically by enterolithotomy (enterotomy with stone extraction). The next step is the closure of the fistulous communication and cholecystectomy. To date, no consensus has been reached regarding whether all of these procedures can be performed at one time. However, our study and a literature review show that enterolithotomy alone is safe and associated with better outcomes than a one-stage procedure, which should be offered only selectively to patients who have good cardiorespiratory reserve ,14. ReisGallstones causing bowel obstruction, known as gallstone ileus, are rare and account for less than 0.5% of small bowel obstruction cases. Additionally, it is a rare complication affecting less than 0.3% of patients who have gallstones. Contrast-enhanced CT of the abdomen and pelvis is a confirmatory imaging study. This condition should be managed with enterolithotomy alone, which is safer than a one-step procedure including fistula closure and cholecystectomy. Endoscopic lithotripsy can only be performed in select patients and only by endoscopists with advanced expertise. However, more research and studies are required to use lithotripsy appropriately and adequately for this condition.


A 51-year-old woman with a history of smoking, Factor XII deficiency, and left temporal lobe anaplastic meningioma operated 1 month before was admitted due to dyspnoea.Figure 1A).Acute pulmonary embolism was ruled out by chest cardiac computed tomography angiography (CTA), but a high-density, hypocaptant, and heterogeneous mass suggestive of either a thrombus or a tumour lesion in the left atrium (LA) was described .Cardiovascular magnetic resonance (CMR) was carried out showing a heterogeneous image, isointense on T1-weighted images (WIs) and hyperintense on T2-WI, with no late gadolinium enhancement, which protruded into the LA from the outlet of the left upper pulmonary vein .Three months later, a meningioma recurrence in the left frontal lobe was treated surgically with a periprocedural temporary suspension of tinzaparin. A week after discharge, the patient was readmitted because of rapidly progressive dyspnoea. A new chest CTA allowed to rule out pulmonary embolism, but the size of the mass had increased, occupying almost the entire LA .Transthoracic echocardiogram (TTE) showed a 55 × 45 mm non-pedunculated multilobulated motionless mass of inhomogeneous echogenicity attached to the atrial posterior wall extending into the pulmonary veins and the mitral valve without impairment on mitral inflow . The LA mass uptake was similar to a biopsied paravertebral lesion in which histological examination proved anaplastic meningioma metastasis. Furthermore, the rapid growth and characteristics of the mass by multimodal imaging support the diagnosis of cardiac metastasis of meningioma. The patient was referred to medical oncology and is currently undergoing chemotherapy.Body fluorodeoxyglucose-positron emission tomography-computed tomography displayed images compatible with metastatic implants in lungs, bones, and muscles (1 The common site for metastasis is the right heart but is very unlikely to metastasize to the LA, although a similar case of metastatic meningioma extending to the LA through the pulmonary veins has been previously described.2 This report emphasizes the rarity of this condition and the importance of a multimodality imaging approach in the assessment of intracardiac masses combining the different information from TTE, CTA, CMR, and nuclear imaging.3Despite the fact that thrombi are the most common cardiac masses, the second most common aetiology is neoplastic, with a secondary/primary tumour ratio of 20:1. Approximately 10% of primary cardiac tumours are malignant and 90% benign.


Paratesticular leiomyosarcoma is a rare urologic cancer that arises from undifferentiated smooth muscles of the spermatic cord or epididymis. Few accounts of this cancer have been reported but previous reports have identified radiation and anabolic steroids as possible risk factors. We report a case of an 83-year-old man with a previous history of radiation therapy for prostate cancer, who presented with a painless left scrotal mass. Given the nonspecific presentation, a histopathological classification was warranted for a definitive diagnosis. The tumor was resected via simple orchiectomy and was diagnosed as a paratesticular grade III leiomyosarcoma without any further treatment. Patient had a follow-up CT scan of the abdomen and pelvis that was normal without metastasis. The patient’s history of previous external beam radiation and now development of a secondary tumor sums to the few cases that have been previously reported with this association. Paratesticular leiomyosarcoma is a malignant soft-tissue tumor that arises from undifferentiated smooth muscle cells most commonly originating from the spermatic cord and the epididymis ,2. It isAn 83-year-old man with past medical history of prostate cancer diagnosed nine years ago and treated with external beam radiation followed by hormonal therapy presented to the primary care provider complaining of a left scrotal swelling. The swelling appeared one or two years prior to presentation but got progressively worse a few months before the visit. The patient denied scrotal pain, redness, urgency, frequency, dysuria or discharge. Family history was remarkable for prostate cancer in his father. On physical examination there was a left scrotal swelling that was non-tender or erythematous and no paratesticular mass was palpable. Right testis was unremarkable. Laboratory findings, including complete blood cell count, complete metabolic panel and urinalysis were unremarkable. Prostate-specific antigen (PSA) was normal for the last eight years. Patient’s tumor markers, which included beta-human chorionic gonadotropin (beta-hCG), alpha-fetoprotein (AFP) and lactate dehydrogenase (LDH) were within normal limits. Scrotal ultrasound revealed normal-sized testicles with a well-defined hypoechoic paratesticular mass located in the superior aspect of the left testicle with internal hypervascularity measuring 4.4 x 4.2 x 5.4 cm Figure . There wThe operative findings were a left hydrocele, atrophic left testis and solid left paratesticular scrotal mass superior to the testicle compromising the vasculature to the left testicle. Left simple orchiectomy with excision of paratesticular scrotal mass and hydrocele were performed. Gross pathology of the specimen  revealed a tan, purple rubbery to firm, semi-saccular tissue, measuring 11.5 x 6.2 x 5.0 cm. The specimen margin was inked in blue and bivalved revealing a circumscribed, firm mass, measuring 8.0 x 5.0 x 4.8 cm. The mass displayed lobulated pale tan-white to focally yellow cut surfaces with scattered necrotic foci (Figure Upon microscopic evaluation, the mass was composed of intersecting, sharply marginated fascicles of spindle cells with elongated, hyperchromatic nuclei, and abundant eosinophilic cytoplasm Figure . There wIntrascrotal tumors are categorized into testicular and paratesticular tumors. Paratesticular tumors account for 7 to 10% of all intrascrotal tumors with 30% of these tumors being malignant . Most coParatesticular leiomyosarcomas usually affect elderly patients in the sixth to seventh decade of life although cases have been reported in younger male adults . ParatesTumor markers like beta-hCG, LDH and AFP are usually negative. Tumor markers in our patient were all negative. Ultrasound is the initial imaging of choice for evaluation of any intrascrotal mass. Leiomyosarcomas can appear on ultrasound as a heterogenous lesion but can also appear as a hypoechoic lesion. CT/MRI can help to differentiate the lesion, but definite diagnosis is made by histological evaluation ,4. Our pRadical orchidectomy with high ligation of the spermatic cord is the standard treatment for these tumors ,5,8. TheParatesticular leiomyosarcoma is a rare type of paratesticular tumor that has been associated with previous radiation therapy in a few cases in the literature. Due to the rarity of this lesion and a broad differential diagnosis of testicular masses, it is commonly misdiagnosed before histological examination. Therefore, histopathology evaluation is the goal standard for definitive diagnosis of leiomyosarcoma since it cannot be diagnosed based on physical exam or laboratory findings. Our patient’s history of previous external beam radiation and now development of a secondary tumor sums to the few cases that have been previously reported with this association.


Intestinal obstruction is an uncommon non-obstetric condition during pregnancy which may cause maternal and fetal mortality. Clinicians are confronted with challenges in diagnosis and treatment of intestinal obstruction due to the overlapping symptoms, concerns over radiological evaluation, and surgical risks.We reported a 39-year old, gravida 7, para 2, woman who suffered from acute intestinal obstruction at 34 weeks of gestation. Ultrasonography and abdominal computed tomography were applied for intestinal obstruction diagnose. Conservative treatment was initially attempted. But following ultrasound found the absence of fluid in the amniotic sac and the patient showed no improvement in clinical symptoms. An emergency caesarean section was then performed. Intra-operative assessment showed dense adhesion between the left wall of uterus and omentum, descending colon, and sigmoid colon. After adhesion dialysis, uterine rupture with complete opening of the uterine wall at the site of left uterine cornua was found without active bleeding. The uterine rupture was then repaired.Although uncommon during pregnancy, clinical suspicion of bowel obstruction is necessary especially in women with a history of abdominal surgery. Surgical intervention is indicated when conservative therapy fails and when there are signs of abnormal fetal conditions and worsened symptoms. The diagnosis and management of acute abdominal pain in pregnancy is a challenging task as multiple conditions can be accompanied with similar symptoms, including obstetric causes and non-pregnancy-related causes. Obstetric conditions include ectopic pregnancy, septic abortion, placental abruption, chorioamnionitis, premature labor, and uterine rupture . The comA 39-year-old, gravida 7, para 2, woman came to the local hospital with a complaint of lower abdominal dull pain for 3 h at 34 weeks’ gestation. Her obstetrical history began with two preterm spontaneous vaginal delivery  at the age of 18 and 19, respectively. Her third, fourth, and fifth pregnancies ended in abortion at early gestation with dilation & curettage treatment. In her previous pregnancy at 36 years of age, she received laparoscopic left salpingectomy and methotrexate (MTX) treatment due to ectopic pregnancy. No other surgeries on the pelvis or abdomen has been performed.Her general condition was stable. Physical examination showed normal secretions, no vaginal bleeding or fluid, no cervical dilation, but irregular preterm contractions with a shortened cervical length. Ultrasonography revealed a decreased amniotic fluid index (AFI 4.0 cm) and a single intrauterine pregnancy with breech presentation and positive fetal heart activity. The placenta was located on the anterior wall of the uterus. Laboratory tests were performed at the time of admission and did not show any significant findings, and hemoglobin level was 120 g/L. Due to the risk of premature birth, dydrogesterone was used to relieve uterine contraction and dexamethasone was administered to accelerate fetal lung maturation. Over 2 days following admission, her symptoms gradually worsened. She presented with diffuse abdominal pain and distension. She also reported nausea and had problem in defecating. Ultrasonography of the abdomen represented intestinal dilatation and multiple intestinal contents and air-fluid levels in the colon. Therefore, an intestinal obstruction was suspected. Enema was used to help intestinal peristalsis.As there was no improvement in her condition, the patient requested a transfer to our hospital. Clinical examination revealed epigastric tenderness and mild abdominal distension, with no signs of guarding or peritonitis. Bowel sounds were weak. Consulting with the surgeon on duty, an abdominal computed tomography (CT) was performed after informed consent from the patient. CT represented dilatation of ascending colon and transverse colon Fig. . The symRe-evaluation of the former abdominal CT was taken, revealing discontinuity of the uterine muscle layer in the left uterine cornua Fig. , which wThe patient recovered well without any complications and was discharged on the fifth postoperative day.It is of paramount importance to appropriately diagnose and treat intestinal obstruction complicating pregnancy as it is associated with significant maternal and fetal mortality. IOP remains the second most common non-obstetric condition for surgical intervention during pregnancy, usually occurring in the third trimester. Reported causes of IOP include postsurgical adhesion, volvulus, intussusceptions, hernia, carcinoma, and idiopathic ileus, of which postsurgical adhesion is the commonest cause. Adhesive obstruction occurs more frequently in advanced pregnancy with 6%, 28%, 45% during the first, second, and third trimester, respectively . In thisDiagnosis of IOP can be difficult to make. Clinical symptoms are often attributed mistakenly to pregnancy and physical examination is often challenging as the gravid uterus poses limitations to proper examination of the abdominal quadrants. Besides, the maternal may be reluctant to take plain films owing to the risk of ionising radiation. Previous literature reviews have demonstrated that radiological methods are acceptable in pregnancy since a single plain abdomen X-ray is around 100 millirads and an abdomen CT scan is around 3.5 rads –14. FetaThe principle of management of intestinal obstruction in pregnant women is similar to non-pregnant states , 15. ConIntestinal obstruction is an extremely rare event during pregnancy but is associated with significant maternal and fetal mortality. It is commonly caused by adhesive bands from previous abdominal surgeries. Obstetricians should be highly vigilant about the diagnosis of bowel obstruction especially in women with a history of abdominal surgery. Diagnostic modalities, including ultrasound, X ray, CT, and MRI, may be offered to pregnant women. Conservative therapy can be initially tried, but surgical intervention must be timely performed when conservative management fails and when there are signs of abnormal fetal conditions and worsened symptoms.


Choroid plexus papilloma (CPP) is rare and even rarer in infants and young children, and it usually occurs in the ventricles. Due to the physical peculiarities of infants, tumor removal by microscopic or endoscopic surgery alone is difficult.A 3-month-old patient was found to have an abnormally enlarged head circumference for 7 days. Cranial magnetic resonance imaging (MRI) examination revealed a lesion in the third ventricle. The patient underwent combined microscopic and endoscopic “chopstick” technique to remove the tumor. He recovered well after the surgery. Postoperative pathological examination revealed CPP. Postoperative MRI suggested total resection of the tumor. Follow-up for 1 month showed no recurrence or distant metastasis.Combined microscopic and endoscopic “chopstick” technique may be a suitable approach to remove tumors in infant ventricles. Choroid plexus papilloma (CPP) is a neuroectodermal tumor that accounts for less than 1% of intracranial tumors . TypicalA 3-month-old patient presented with an abnormally large head circumference for 7 days. He was born vaginally at full term, without asphyxia or birth injuries, and was breastfed after birth. Growth and intelligence were appropriate for his age. On examination, the fontanelle pressure was high, the head circumference was 45 cm, and the eyes were gazing downward. Ultrasound examination performed at other hospitals suggested hydrocephalus. Cranial magnetic resonance imaging (MRI) showed the presence of a space-occupying lesion in the third ventricle, about 3.8×4.6×3.1 cm  . We systSixteen duplicate records were removed by database search. A total of 197 records were left for title and abstract checking. Forty full-text articles were evaluated. Eighteen articles were finally included for analysis Figure 4CPP is a rare intracranial tumor that is classified as grade I by the WHO tumor classification. In pediatric patients, CPP usually occurs within 1 year of birth and is most commonly located in the lateral ventricle 64%) . Accordi% . AccorIn our report, the lesion was first resected using the microscopic access through the frontal cortex, and then the tumor in the blind area of the microscope’s visual field was removed by endoscopic “chopstick” technique to achieve complete resection. In the “chopstick” technique, the endoscope and suction device are held in the left hand. The light source connector of the endoscope is placed between the thumb and ring fingers, and the direction can be changed as required during the operation. The suction device is placed between the index and middle fingers. A 0° or 30° endoscope can be used depending on the location of the lesion. This provides a new method for total resection of ventricle tumors with minimal trauma. Clearly, as this is a case report only, more studies with appropriate design and larger size are needed to provide stronger evidence level.Microscope combined with endoscopic “chopstick” technique may be a new way to remove the tumors in the ventricle.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Investigation: WL, CW, XY. Methodology: HL, ZL. Project administration: HL, WL. Resources: HL, ZL. Supervision: HL. Histopathological examination: YJ. All authors contributed to the article and approved the submitted version.


Cases of genital amputation require a careful investigation, since they may be the result of self-inflicted injuries, assaults, animal predation, or post-mortem body mutilation. In the present case, an 81-year-old man affected by liver cirrhosis and dementia and suffering from sexual disinhibition was found lying half-naked and unconscious in his courtyard; profuse bleeding in the perineal area and the absence of the external genitalia were observed. The victim was transferred to hospital and underwent surgical emergency treatment, but he died 2 days later. No sharp tools were found on the scene. Moreover, the autopsy did not reveal any defense or tentative wound on the body and no blood stains on the hands of the victim. Several linear scratches were detected close to the edges of the wound; according to the surgical report, these scratches were clean-cut in the lower part and crenated and infiltrated by blood in the cranial part. Although the medical history of the man could be consistent with self-mutilation, it was not possible to rule out the involvement of other people, including the possibility of an attempt by his relatives to cover up what may have been a self-amputation. Furthermore, the victim’s dog vomited parts of the man’s genitalia while being transported to a dog shelter. Similar cases have rarely been published in the current forensic literature. Male genital mutilations include a wide spectrum of lesions, ranging from cultural practices and the insertion of plastic spherules under the skin of the penis to the removal of one or both testes (castration) or the complete amputation of penis, scrotum and testes. They may be self-inflicted or arise from accidents, assaults and animal predation, and may occur before, after or around the time of death –3.The aim of this paper is to present an unusual case involving an elderly man affected by dementia who was found bleeding due to a complete mutilation of the genitals. He underwent reconstructive surgery, but died two days later. The man’s dog vomited part of his genitalia. The injury in the pubic area was partially characterized by clean edges, but no weapon was found during the scene investigation.The case occurred in 2001 and was mentioned in a previous study .One day in September around 11.30 am, an 81-year-old man was found lying unconscious and supine in a pool of blood in his courtyard by his caregiver. The man was wearing an undershirt, which was smeared with blood in its lower part, and was bleeding from a wound in the genital region. The caregiver called the paramedics and some of the man’s relatives, and the victim was transferred to hospital.Several relatives of the victim were on the scene at the arrival of the investigators. No other blood patterns were noted. Furthermore, there were no signs of struggle or burglary and no sharp tools were found.According to the paramedics, blood was only present in the genital area and on the lower abdominal regions of the victim; no blood was found on his hands and forearms.The victim had a small half-breed dog, male and unneutered, which vomited while being carried to a dog shelter. The vomited material was found to contain part of the victim’s genitalia, as confirmed by the histological examination Fig. A. The prOn arrival at the emergency department, GCS was 8/15, blood pressure was 60/40 mmHg and Hb levels were 10.2 g/dL. Profuse bleeding was noted in the genital area, and head CT scans were negative for acute lesions. The man was intubated and brought to the operating room.According to the surgeon’s report, the lower edges of the wound were sharp, while the upper ones were irregular, crenated and showed a subcutaneous hemorrhage.Wound exploration and debridement were performed before oversewing the corpora cavernosa. What was left of the bulbous urethra was re-fashioned through a perineal urethrostomy, and a urethral catheter was inserted. Despite being transferred to the intensive care unit (ICU) and being treated with blood transfusions, packed red blood cells, oxygen supply, and positive inotropic agents, the man died two days after admission.The man suffered from sexual disinhibition caused by dementia, had been treated for a left temporal intracerebral hemorrhage, and had a history of alcohol abuse. Furthermore, he suffered from persecutory delusions and used to hide a large knife (which was not recovered) under his pillow.At autopsy (performed one day later), different clusters of parallel abrasions were noted on the right trochanteric region, on the right side of the groin and on the medial aspect of the left thigh. No injuries were observed on the upper limbs. A longitudinal surgical incision sewn with staples was found in the pubic region. Blood-infiltration of the edges of the wound was slight in the lower part of the injury and more significant in the upper part Fig. .Fig. 2A,Other relevant findings included cerebral atrophy, liver cirrhosis Fig. B, coronaToxicology was performed on peripheral blood that had been sampled on admission to hospital before blood transfusion, on bile specimens collected at autopsy and on the gastric content of the dog. Traces of nicotine and lidocaine were found in the blood samples. The cause of death was attributed to hypoxic ischemic encephalopathy resulting from exsanguination caused by a mutilation to the genital area.Autopsies on bodies with genital mutilation require a careful approach in order to correctly establish the manner of death , 5. In tDeath due to hemorrhage as a result of genital mutilations is rare , 6, 7. IAt autopsy, the aforementioned surgical treatment influenced the analysis of the wound. In such cases, the medical record can provide crucial information, since surgery and hospitalization may result in the alteration or onset of wounds .The vomited material included part of the victim’s genitalia. During the examination of the wound in the operating room, the edges were found to be cut-off in the lower part, while they were irregular, crenated and accompanied by scratch-like abrasions in the upper part.The margins of the lower part were consistent with a sharp-force injury, whereas, as regards the upper margins and the vomited genitalia, the hypothesis of dog predation had to be considered.Wounds inflicted by dogs can be classified as non-fatal bite wounds, fatal bite wounds, and post-mortem lacerations .Dogs usually target the head, the neck, the throat and any exposed part of the body, with the genitalia being occasionally consumed –13. DogsThe typical injury pattern caused by dog bites, named “hole and tear”, is the consequence of a combination of biting, clawing, and crushing, with a round “hole” made by the canine tooth penetrating into the skin, whereas the other teeth cut into the flesh and cause stretch lacerations due to the shaking of the head (the “tear”) , 12, 14.Considering the lack of bite wounds on the lower limbs and the absence of defense injuries, it was likely that the man was already lying on the ground when the dog attacked him and that he did not attempt to defend himself.Furthermore, taking into consideration the features of the wound and the presence of parallel scratches close to the injury, the hypothesis of the dog having amputated and then consumed the genitals could be ruled out.Since the interpretation of dog-inflicted wounds can be misleading, an odontological examination of the bite marks and the DNA analysis of the saliva recovered on the victim’s body can assist the forensic pathologist in identifying the animal , 16.In the present case, such methods might have been affected by the way the wound had been treated during surgery.The peculiarity of this case consists in the fact that the victim was still alive when his genitals were eaten: cases of dogs eating their dead owners have been frequently reported, whereas dog injuries are extremely rare on unconscious victims –19.The literature reports the case of a dog that vomited human parts and dog food, as well as cases of post-mortem genital predation by dogs on a 49-year-male who had died of myocardial infarction and on a young man who had hanged himself , 13, 20.Another key point was the presence of sharp edges in the lower part of the wound, which raised the possibility of an assault.Given that no signs of struggle were noticed and that blood was only found on the man’s body, the fact may have occurred in the same place where the man was found.However, the involvement of other people could not be ruled out, as the scene may have been altered by the victim’s relatives in order to cover up the nature of the self-injury , 22.The lack of damage to the undershirt and the presence of the injury on an unclothed part of the body were consistent with a case of self-injury, but could not rule out an aggression. Tentative wounds were not observed .Moreover, defense wounds may also be missing in homicide victims who suffer a single sharp-force injury, if the victim is attacked suddenly or if his/her ability to act is reduced. The latter hypothesis was not supported by the toxicological and autopsy findings –26.Homicidal injuries to the genital area are rare and are typically associated with sadistic and sexual homicides , 27. PerCases of elderly victims (mostly women) often involve other offenses, such as burglary .A considerable number of non-fatal cases where women cut off the penis of their male partner while the man slept was documented in Thailand in the 1970s .In the present case, since the victim was found in his courtyard and no signs of struggle were found, the abovementioned hypothesis was unlikely.The other hypothesis concerned male genital self-mutilation (GSM) resulting in complete emasculation , 8.Suicidal attempts through GSM are rare and often unsuccessful, while GSM is more frequent in cases of self-harm , 30–32.GSM is often associated with psychiatric conditions. However, GSM is sometimes performed by non-psychotic individuals for aesthetic and social purposes, for distorted religious beliefs or to seek sexual reassignment surgery , 33–38.The large majority of individuals performing GSM are males in the third and fourth decades of life , 39, witIn a recent paper, a 60-year-old man with a history of fronto-temporal dementia inserted a spoon into the urethra during a stay in hospital .In the present case, a complete amputation of the genitals was observed in an elderly man who suffered from dementia and sexual disinhibition and who was found lying unconscious and bleeding in his courtyard. Despite reconstructive surgery, he died two days later. The dog of the victim vomited part of the man’s genitalia.According to the surgeon’s report, the wound had sharp edges on its lower part and irregular and crenated edges with subcutaneous hemorrhage on the upper part, leading to the hypothesis that the amputation may have been the result of a cut wound, followed by ante-mortem dog predation with the victim lying on the ground. However, although the absence of defense injuries and the history of the victim were suggestive of self-mutilation, the lack of a weapon could not rule out the involvement of a third party.Consequently, the death remained undetermined, since, according to Italian law, the manner of death must be ascertained as per the legal standard of “beyond reasonable doubt”.This case was characterized by several key points.Genital amputation, whether self-inflicted or performed by assailants, is uncommon among elderly, with fatal cases being rare.Furthermore, sharp-force injuries are rarely associated with ante-mortem dog predation.Lastly, if a victim has been hospitalized and undergone surgery before dying, the importance of the medical records should not be understated, since injuries may be altered considerably during surgery.An elderly man was found unconscious in his courtyard without external genitaliaNo sharp tools were found and the victim’s dog vomited part of his genitaliaTentative and defense wounds were not present and the man died after surgeryThe lower wound edges were sharp, while the upper ones were infiltrated by bloodNeither self-mutilation nor the involvement of other people could be ruled out


Gastrosplenic fistula (GSF) is an unusual event that might occur in patients with various gastric or splenic diseases. While GSF related to gastric and splenic malignancies is well-documented in the literature, cases of GSF due to a splenic abscess are extremely rare. We experienced the case of a 49-year-old man with a medical history of tricuspid cardiac valve replacement for infective endocarditis who presented with a sudden onset of anemia and melena. With the assistance of imaging and endoscopy, a primary splenic abscess complicated by spontaneous GSF was diagnosed. A prompt splenectomy with partial gastrectomy was performed. GSF is a serious occurrence associated with a high risk of morbidity and mortality. The early recognition of GSF related to a splenic abscess is crucial to prevent major complications. Surgical resection with splenectomy and partial gastrectomy is frequently preferred for the treatment of large abscesses with GSF. Gastrosplenic fistula (GSF) is a rare occurrence that primarily arises as a complication of gastric or splenic malignant tumors . AlthougThe patient is a 49-year-old Caucasian male with medical history of HCV-HBV infections, substance use disorder, and tricuspid cardiac valve replacement using a bioprosthetic valve due to complications from infective endocarditis. Subsequently, a left-brain hemisphere stroke and splenic embolizations occurred.A transesophageal echocardiogram revealed hyperechoic images in both mitral valve leaflets with medium-grade valve insufficiency and tricuspid dysfunction. Peripheral venous blood cultures yielded negative results, and empiric antibiotic therapy was initiated. Infective mitral valve endocarditis was staged using an abdominal computed tomography (CT) scan with contrast medium, which identified an 8 × 7 cm neoformation at the upper pole of the spleen, consistent with an abscess lesion .Two weeks later, an endoscopic ultrasound was performed, revealing an abscess collection measuring 7 × 6 cm in the upper pole of the spleen. The portion of the collection adjacent to the splenic parenchyma did not appear to be encapsulated, and drainage of the abscess using a metal prosthesis would likely have caused pressure on healthy splenic tissue.As a result, the patient underwent six consecutive abdominal ultrasounds, which demonstrated a gradual reduction in the size of the splenic collection (minimum diameter: 4 cm).Three months after the diagnosis of splenic abscess, the patient experienced a sudden onset of anemia and melena. An abdominal CT scan revealed a large blood collection  replacing the upper pole of the splenic parenchyma . The splAn exploratory laparotomy was performed, revealing numerous clots around the spleen and a large splenic abscess with inflammatory adhesions to the gastric fundus and left diaphragm. En block resection of the spleen along with a portion of the gastric fundus was carried out .Histopathological examination (HPE) showed a splenic blood–abscess collection with GSF and adhesive perisplenitis involving adjacent tissues, but no evidence of malignancy.The postoperative period was uneventful.To our knowledge, there have been six reported cases of GSF resulting from benign splenic diseases . Among tet al. [Kryshtalskyj et al.  describeet al. [Ballas et al.  reportedet al. [Leeds et al.  publisheet al. [Alsinan et al.  describeGSF is a serious complication that can arise from various gastric and splenic diseases, often requiring prompt embolization or surgical intervention in cases of significant bleeding . Most coGSF often does not present with severe hemorrhage, and short-term outcomes are generally favorable, with a survival rate of approximately 82% [The diagnosis of GSF is typically suspected based on CT imaging, which reveals air in the spleen, and is confirmed through upper gastrointestinal endoscopy, allowing direct visualization of the fistulous communication .The treatment approach should consider the underlying cause of GSF. However, it can be challenging to determine whether GSF is a result of silent gastric perforation with secondary splenic abscess or a primary splenic abscess leading to the formation of a communication with the stomach.Conservative treatment with percutaneous drainage and antibiotic therapy is often inadequate for GSF patients with large splenic abscesses. In such cases, the most common treatment is splenectomy with partial gastrectomy, aiming to prevent major complications, including massive bleeding .GSF is an uncommon complication associated with splenic abscesses. Early recognition of GSF related to splenic abscess is essential to prevent significant complications, such as severe bleeding. Although conservative approaches are possible, surgical resection involving splenectomy and partial gastrectomy is often the preferred treatment for large abscesses with GSF. In such cases, the presence of active bleeding further reinforces the necessity of surgical intervention.


An obese middle‐aged man presented for left abdominal pain. CT scan with contrast medium revealed hematoma in the left abdominal internal oblique muscle. There was no history of trauma or respiratory disease. He was referred to our hospital due to persistent left‐sided abdominal pain.A 40‐year‐old man with a body mass index of 43 kg/mAbdominal computed tomography (CT) with contrast medium revealed abdominal internal oblique muscle hematoma (160 × 160 × 80 mm in size) in the left side (Figure Cough is a reflex, which is vital for protecting the airway from secretions and foreign substances. However, strong cough can cause skeletal muscle complications.Patients with abdominal wall hematomas are mostly treated conservatively with bed rest and analgesics. Invasive treatment is only indicated if hematoma enlarges or perforates into the abdominal cavity.None.Written informed consent was obtained from the patient for publication of this clinical image.Ethical approval by the institutional review board of Asahi General Hospital, was not required at the authors' institution for this case report.


Mucinous neoplasms are commonly seen in the ovaries and pancreas. Their occurrence in the retroperitoneum is uncommon. We present a case of a retroperitoneal mucinous cystadenocarcinoma in a 54-year-old female who presented with right flank pain. Imaging demonstrated an 8.6 × 7.9 cm mass at the anterior surface of the lower pole of the right kidney, suspicious for renal cell carcinoma. Serum tumor markers carbohydrate antigen 19-9 (CA 19-9) and cancer embryonic antigen (CEA) were within normal limits, and cancer antigen 125 (CA 125) was elevated. Surgical resection of the mass was performed. Intraoperatively, the mass was noted to lie in the retroperitoneum, unattached to the kidney. On gross examination, a 10.0 × 7.0 × 7.0 cm unilocular cystic structure with red-brown mucoid material was present. The inner lining was mostly smooth with areas of excrescences, covering less than 5% of the surface area. Microscopic examination showed cystic areas lined by mucinous epithelium with an underlying ovarian-type stroma. Solid areas showed features of a borderline papillary mucinous tumor with invasive carcinoma. A diagnosis of mucinous cystadenocarcinoma was made. Their occurrence in the retroperitoneum is unusual. Although rare, this entity should always be considered in the differential diagnosis of retroperitoneal cystic lesions. Mucinous cystic neoplasms are known to occur in the ovaries and pancreas. However, in rare instances, they are found to occur as primary retroperitoneal masses . They arA 54-year-old female presented with complaints of right flank pain. The pain had been progressively increasing in intensity over the previous year. Her past medical and surgical history was significant for hypothyroidism, hyperlipidemia, depression, and sleeve gastrectomy for morbid obesity, with hiatal hernia repair. Physical examination was within normal limits.Multiple modalities of imaging were obtained. CT with contrast demonstrated an 8.6 × 7.9 cm mass at the anterior surface of the lower pole of the right kidney with peripherally enhancing mural nodules at the superior and inferior margins of the mass Figure . The larSerum tumor markers carbohydrate antigen 19-9 (CA 19-9) and cancer embryonic antigen (CEA) were within normal limits; however, cancer antigen 125 (CA 125) was elevated at 46 U/mL . Given these findings, a decision was made to remove the mass laparoscopically as a partial right nephrectomy. Intraoperatively, a large mass was seen protruding from the retroperitoneum, just lateral to the colon and adherent to it. It was not attached to the kidney. Intraoperative ultrasound of this mass demonstrated a homogenous structure. The mass was then carefully removed and sent for pathological examination.A gross examination of the mass revealed a 10.0 × 7.0 × 7.0 cm unilocular cystic structure with a smooth surface and attached adipose tissue Figure . The cysHistopathologic examination showed that the tumor was found to be partly cystic and partly solid Figure . The cysOvarian and pancreatic mucinous cystic neoplasms are very well known. However, primary retroperitoneal mucinous neoplasm is rare. It was first described in 1924 by Handfield‐Jones ,4. The sAs noted, these tumors mostly occur in women, although few cases have been reported in men . In mostThe correct diagnosis prior to surgery is challenging. Although CA 125 was elevated in our patient, serum marker assays are not usually useful, as their expression is variable. Additionally, in our patient, the cyst appeared to have arisen from the kidney radiologically with a strong suspicion of renal cell carcinoma. However, intraoperatively, it was seen to be separate from the kidney, and microscopic examination confirmed the absence of renal tissue. Thus, diagnosis is almost entirely based on histopathology.Usually, these lesions tend to begin as benign tumors and proceed to acquire malignant features. This theory holds in our case as the patient had a radiologically evident lesion a few years prior that was smaller in size and progressed to the current lesion. Histologically, the presence of borderline areas and foci of invasion support the transformation from a benign cystadenoma to a malignant cystadenocarcinoma.Complete surgical resection of the retroperitoneal mass is recommended because of the possibility of malignancy; complications such as infections are also likely. Although a few authors suggest prophylactic bilateral salpingo-oophorectomy, with or without hysterectomy, to improve survival, there are no studies to support this recommendation -11. In cMucinous cystic neoplasms are rare primary retroperitoneal masses, more commonly found in women, and are typically asymptomatic, leading to a delayed diagnosis. Histopathologic examination plays a key diagnostic role in these cases as they are clinically and radiographically challenging, often being diagnosed as ovarian or renal masses.


Appendiceal collision tumours are extremely rare, with most reported cases describing tumours consisting of a mucinous component and a neuroendocrine component. Low-grade appendiceal mucinous neoplasms, in some cases, have a tendency to rupture and disseminate their mucin-producing cells throughout the abdominal cavity, leading to a clinical syndrome known as pseudomyxoma peritonei (PMP). We present the case of a 64-year-old male who initially presented with acute appendicitis and was subsequently found to have PMP and appendiceal malignancy. After several years of scans, surgical intervention and histological analysis, it became apparent that the appendiceal malignancy was comprised of distinct cell types. The patient underwent two rounds of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, which resulted in a 2-year disease-free period. Unfortunately, the PMP recurred, having morphological changes consistent with a more aggressive disease process. Appendiceal collision tumours are an extremely rare clinical entity, having only been described in a handful of published reports. Pseudomyxoma peritonei (PMP) is also a rare pathology, with an estimated incidence of 1 per million per year .We report an extremely rare case of PMP, coexisting alongside an incidental LAMN and neuroendocrine appendiceal collision tumour.A 64-year-old male presented to the Emergency Department with a short history of abdominal pain. On examination he was tender and exhibited guarding in the right iliac fossa. Clinically, he was diagnosed with appendicitis and underwent a computed tomography (CT) scan. The CT scan demonstrated findings in keeping with acute appendicitis, however, also noted extensive caecal thickening with multiple reactive lymph nodes in the adjacent mesentery. The reporting radiologist also commented on an ill-defined 2.3 cm subphrenic opacity, as likely to be of no significance, but the possibility of a peritoneal nodule should not be ruled out. This episode was managed conservatively.In view of the initial CT findings, a colonoscopy was performed which ultimately revealed no abnormalities in either the mouth of the appendix or the caecum. Multiple biopsies were taken that showed no evidence of dysplasia or malignancy. A repeat CT at 3 months showed considerable improvement in the appearances of the appendix, caecum and adjacent mesentery. Some residual thickening of the caecal pole and appendix remained, but there was no evidence of intraperitoneal metastatic disease or other cause for concern.About 1 year later, the patient re-presented for anaemia and underwent a further CT scan. In the right iliac fossa, a 51.96 mm mass was noted such that the appendix could not be visualized separately, with a focus of calcification . There wAt 6-months post-diagnosis, the patient underwent cytoreductive surgery with right hemicolectomy and cholecystectomy, and hyperthermic intraperitoneal chemotherapy (HIPEC), having a peritoneal cancer index (PCI) of 28 and completeness of cytoreduction (CC) score of 1. Histology from specimens showed disseminated peritoneal adenomucinosis (DPAM), as well as an incidental 15 mm grade 1 well-differentiated neuroendocrine tumour , identified in the LAMN and infiltrating into the caecum. This neuroendocrine tumour was completely excised. The patient underwent a redo cytoreductive surgery with splenectomy and HIPEC 16 months later, following identification of a 10 mm recurrence in the left paracolic gutter, with a PCI of 11 and CC of 0. Histology again confirmed DPAM.Following these operations, the patient fared well and was disease-free according to imaging. He was quoted a 5-year survival rate of over 85%.Unfortunately, 2 years later the patient was repeatedly admitted acutely to hospital with vomiting and physical deterioration. CT scans revealed a cystic mass surrounding the jejunal loops and re-appearances of peritoneal deposits, in keeping with aggressive progression of PMP . The perIt was decided to perform a laparotomy and insert a surgical gastrostomy with the aim to start total parenteral nutrition and facilitate a safe discharge home. The biopsy performed of the peritoneal deposits showed a change in morphology to grade 3 mucinous carcinoma peritonei with signet ring cells. The patient declined chemotherapy and sadly died 6 months later.The simultaneous presence of mucinous and neuroendocrine neoplasms in the appendix is exceptionally rare, with few reported cases , 4. CollPMP is a rare clinical entity, characterized by diffuse intra-abdominal mucinous implants on peritoneal surfaces. The ‘redistribution phenomenon’ describes the flow of intraperitoneal fluid and the effect of gravity on the ability for free-floating mucinous epithelial tumour cells to implant in various parts of the peritoneal cavity. The small bowel is relatively spared due to its peristaltic movements preventing tumour cells from adhering . Diagnoset al. showed the 5-year survival rates were 87% in patients who underwent complete cytoreduction versus 34% in those patients who underwent solely major debulking of the tumour [Due to the rarity of the disease, there is no standard for management. However, studies advocate the use of cytoreductive surgery and HIPEC for good surgical candidates . A studyOur case highlights the imperative need for surveillance in patients with PMP. Even though our patient had a disease-free interval, and was quoted a favourable life-expectancy, unfortunately the disease process recurred with a change in morphological features to a more aggressive cancer type.


Intestinal polypoid lymphangiectasia is an uncommon disorder involving an improperly formed enteric lymphatic system. It is characterized by lymphatic vessel dilatation with impaired drainage or obstruction of the lymph from the intestine. In this report, we present a case of a 73-year-old male patient with chronic intermittent left lower quadrant abdominal pain for one year who was found to have a sigmoid colon polyp on a colonoscopy. Upon microscopic examination, the polyp revealed dilated lymphatic vessels staining strongly for D2-40 (lymphatic vessel marker), supporting the diagnosis of polypoid lymphangiectasia. Intestinal lymphangiectasia has a broad differential diagnosis, warranting histopathological examination for a definitive diagnosis. Intestinal polypoid lymphangiectasia is an uncommon disorder characterized by an improperly formed enteric lymphatic system with a mass lesion protruding from the mucosal surface into the intestinal lumen . It invoA 73-year-old male presented to the primary care clinic for his regular yearly check-up. The patient complained of severe intermittent non-radiating abdominal pain localized to the left lower quadrant for a duration of one year. He also had associated occasional constipation. There were no complaints of nausea, vomiting, weight loss, hematochezia, or melena. No specific triggers were identified. His pain was not associated with food intake or bowel movement. The patient had a significant medical history of hypertension, hypogonadism, non-insulin-dependent diabetes, benign prostatic hyperplasia, and gastroesophageal reflux disease (GERD). No colonoscopy had been performed previously, and no family history of inflammatory bowel disease or colon cancer was reported. An abdominal exam showed a soft, non-distended, non-tender abdomen with normoactive bowel sounds. With regard to lower extremities, no peripheral edema was noted.The patient underwent a blood examination, which showed a total protein of 7.8 g/dL and albumin of 3.7 g/dL. His lipid profile, which included triglycerides, LDL, and HDL, was within the normal range. A CT scan of the abdomen and pelvis was performed, which showed a triangular soft tissue opacity in the sigmoid colon measuring about 26 x 18 mm on the coronal image, with diffuse colonic diverticula, without any convincing evidence of focal acute diverticulitis  Figure . Two sesLymphangiectasia is a rare pathological dilation of lymphatics seen in the intestines and hence termed “intestinal lymphangiectasia''. It can impair the lymph flow, leading to obstruction from enlargement, and can lead to loss of protein . In chilIn our case, the lesion was present in the colon, as opposed to the more common location of the small intestine. In addition, instead of the commonly seen white spots/specks on endoscopy, our case presented as a polypoid lesion. The sigmoid polypectomy microscopically was composed of submucosal dilated vessels, which were evaluated further with D2-40 (lymphatic vessel marker) stain. The D2-40 stain highlighted that the vessels were lymphatic vessels with a lack of surrounding endothelial lining or smooth muscles. These findings helped confirm the diagnosis of polypoid intestinal lymphangiectasia.It is vital to further investigate such a rare finding in this patient population in order to rule out underlying etiologies such as Waldenström macroglobulinemia, inflammatory etiologies, sarcoidosis, or other mass-forming intestinal malignancies . Other dDiagnostic testing for lymphangiectasia usually involves intestinal endoscopy and biopsy with histological evaluation. Histological evaluation is warranted to arrive at the final diagnosis as it helps determine if it is lymphatic-based or not. If endoscopic visualization and biopsy fail to confirm a diagnosis, lymphangiography may also be utilized in the diagnostic workup.The management of lymphangiectasia appears to be similar regardless of whether the cases are found in the small intestine or colon. Treatment with a strict low-fat diet and supplemental medium-chain triglycerides is necessary for all patients with this condition . Medium-Literature on the outcomes of intestinal lymphangiectasia is currently limited due to the uncommon nature of the disease. However, one literature review study in 2010 found that dietary intervention is effective in a majority of cases (around 63%). Additionally, they reported malignant transformation of lymphoma in 5% of patients ranging in age between 19 and 45 years after primary intestinal lymphangiectasia onset [Intestinal polypoid lymphangiectasia is an uncommon disorder that requires imaging, laboratory assessment, and histological evaluation for a definitive diagnosis. We discussed a unique case presenting as a polyp in the sigmoid colon instead of the common presentation of white spots in the small intestine. A diagnosis of intestinal lymphangiectasia warrants further evaluation to rule out underlying etiologies such as Waldenström macroglobulinemia, inflammatory disease, sarcoidosis, and malignancy. In addition, raising awareness about this disorder is essential since patients are at risk of gastrointestinal bleeding and other comorbidities associated with PLE.


Stercoral ulcers are caused by persistent fecal impaction. A life-threatening consequence of stercoral ulcers is colonic perforation, which is rare. A high index of clinical suspicion should be held for patients with stercoral ulcer, as colonic perforation is a medical emergency, requiring immediate surgical intervention. Here, we report a case of a 45-year-old female admitted with sepsis of unknown picture and subsequently developed stercoral ulcer perforation (SUP), diagnosed intraoperatively, without prior radiographic evidence of colonic inflammation. She was successfully managed with emergency laparotomy and left colectomy with sigmoid colectomy. Stercoral colitis is a rare inflammatory process most commonly of the rectosigmoid colon related to prolonged fecal impaction associated with chronic constipation and colonic dysfunction . IschemiWe report a case of a 45-year-old female with past medical history of chronic constipation from methadone, gastroesophageal reflux disease presented with diffuse lower abdominal pain that began one day ago. Her last bowel movement was eight days ago. On presentation, blood pressure 112/58 mmHg, heart rate 106/min, saturating well on room air, and afebrile. On abdominal exam, tenderness prominent in the lower quadrants with guarding and diffusely dull resonance. Labs were significant for white blood cell (WBC): 16,400/µL with 90% neutrophil percent, hemoglobin 12.1 g/dL, platelets 275,000/µL, and lactic acid 2.2 mmol/L. Urinary analysis was negative for any infectious etiology. CT of the abdomen and pelvis with contrast showed large stool throughout the colon without any acute colonic pathology Figure ,b.She was started on Piperacillin/Tazobactam and was admitted for sepsis of unknown origin.A day after admission, the patient described a popping sensation in the lower right quadrant with stabbing pain that radiates to the right clavicle. Physical exam revealed an abdomen that was diffusely distended with positive rebound tenderness, guarding, and tympanic resonance. CT angiogram of abdomen and pelvis was consistent with pneumoperitoneum with localized inflammation and perforation in the sigmoid colon Figure ,b.The patient emergently underwent exploratory laparotomy and upon entry of the peritoneal cavity, feculent and purulent fluid was encountered. A large perforated stercoral ulcer in the rectosigmoid was identified with fecalomas protruding through the perforation as well as the entire length of the left colon. Despite undergoing colonic lavage, impacted stool persisted throughout. Due to an increased risk of perforation, the patient underwent an extended left colectomy with sigmoid colectomy. Intra-abdominal cultures taken during the procedure grew polymicrobial microorganisms including those that produce extended spectrum beta-lactamases (ESBL). The patient completed a course of ertapenem and was discharged.Stercoral perforation has high mortality rates , 4. EarlPatients present with benign symptoms with non-perforated stercoral ulcers: abdominal pain, vomiting, rectal discomfort, constipation, etc. Patients with perforation have bloody stools with signs of peritoneal inflammation . Our patCT abdomen has an important role in identifying this life-threatening complication of stercoral ulcers. Some of the findings are: colonic dilatation >6 cm, colonic wall thickening >3 mm, pericolonic fat stranding, mucosal discontinuity, presence of free air, free fluid, and pericolonic abscess , 5. InitThe diagnosis is made during exploratory laparotomy and fecalomas coming through the perforated ulcer is diagnostic . SimilarWithout surgical intervention, SUP has 100% mortality. Even with surgical intervention, the prognosis is poor -8. The iWe report a rare case of stercoral perforation without radiographic studies showing stercoral colitis, ulcer, or fecal impaction that increases the risk of SUP. Diagnosis of SUP was made intraoperatively in our patient. This is the first case report with a negative CT abdomen in a patient with SUP. We conclude the importance of developing a high suspicion for complications of chronic constipation, including bowel perforation. This is especially true when there is a change of clinical symptoms, particularly with signs of peritonitis.