Abdominal cocoon and peritoneal loose body are both rare abdominal diseases.The patient reported in this case was a 47-year-old man who suffered from abdominal pain and distension for 3 days.X-ray, computed tomography, and magnetic resonance imaging revealed multiple peritoneal loose body and small bowel obstruction, characterized by a total encapsulation of the small bowel with a fibrous membrane.The patient underwent surgical treatment and exploratory laparotomy confirmed the diagnosis of abdominal cocoon.Histopathological examination of pelvic nodules confirmed peritoneal loose body.To our knowledge, the herein reported case is the first abdominal cocoon that was accompanied by multiple peritoneal loose body. Clinical symptoms of AC were often nonspecific, and PLB rarely resulted in clinical symptoms. In the previous literature, there was no report of AC combined with PLB. Herein, we report the X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) findings of a case of AC accompanied by multiple PLB.Abdominal cocoon (AC) is a rare clinical abdominal syndrome characterized by cocoon-like intestine due to all or part of the small intestine, which is covered by a layer of dense, gray, and white fibrous membrane. The preoperative imaging diagnosis was difficult.2A 47-year-old man suffered from abdominal pain and distension, accompanied by nausea and vomiting for 3 days. The patient had a history of frequent abdominal distension. He had no history of trauma or surgery. A local abdomen examination revealed a large lump in the middle lower abdomen with no obvious tenderness. The boundary of the lump was not clear but soft. The bowel sound was normal. Routine laboratory studies demonstrated no abnormalities.This study was approved by Ethic Committee of Binzhou Medical University and the patient provided the written informed consent to participate in this study. X-ray of the abdomen showed small bowel dilatation in the middle lower abdomen with several step-ladder like air-fluid levels and a number of bead-like high-density nodules with clear boundary in pelvic cavity Fig. . CT scanExploratory laparotomy revealed extensive membranous adhesions in abdominal cavity. The entire small intestine was wrapped around with gray and white fibrous membrane. About 30 cm of the small intestine expanded significantly with thick contents at the right abdomen. Abdominal cocoon was diagnosed intraoperatively. Lysis of adhesions and intestinal arrangement were performed Fig. . Multipl3–4Abdominal cocoon is also called sclerosing encapsulating peritonitis and is divided into primary and secondary types. Primary AC is a disease of uncertain origin. It may be due to poorly developed greater omentum in the embryonic stage which downs the colon transversum and encapsulate small intestine. Secondary AC often has multiple causes such as abdominal dialysis, long-term therapy of beta blocker use, abdominal tuberculosis, peritonitis, liver cirrhosis, abdominal surgery history, organ transplantation, systemic lupus erythematosus, and gastrointestinal malignancies. All of these ingredients can stimulate peritonitis and lead to a large amount of fibrin in the abdominal cavity. Due to absorption disorders and connective tissue proliferation, a layer of dense fibrosis capsule may be formed to encapsulate the small intestine eventually.–7The accurate cause of peritoneal loose body remains unknown. The main sources include appendices epiploicae, intestinal fat, greater retinal fat, fat deposits of lymph nodes, fat in the pancreas, etc. Free floating loose bodies are formed due to ischemia, necrosis, and exfoliation of adipose tissue in these sites. Then internal calcifications occur gradually, and their volumes snowball slowly due to continuous absorption of the protein in the ascites. Pathological observations revealed a calcified layer in the center of the free body around fat. Peripheral substances like “cooked chicken proteins” were homogeneous, red dye fibrous connective tissue with concentric lamellar arrangement, supporting this hypothesis.–7AC is lack of specific clinical manifestations, and the initial clinical symptoms are intestinal obstruction or/and abdominal mass. AC may recurrently attack, be subsided, or increasingly get severe. The shape and size of most intraperitoneal free bodies are mainly round or oval mass with 0.5 to 2.5 cm in diameter, similar to this case. These PLB rarely cause symptoms. However, when the size of PLB in diameter increases from 5 to 9.5 cm, pelvic organs can be compressed due to the limited space of pelvis. Sometimes, incomplete intestinal obstruction and the symptoms of frequent urination may occur.,2,8 enveloped sign is of great value in the diagnosis of the disease. When small bowel obstruction occurs with no clear cause, it should be carefully observed whether the small intestine could be encapsulated by fibrous membrane, especially in the liquid accumulation area or fat accumulation zone outside the intestine.AC can be divided into localized and diffuse types according to the scope of the encapsulated small intestine. The former is partial involvement of small bowel and the latter is total involvement of small bowel. The characteristic imaging findings of AC are envelope sign, defined as the small intestine surrounding by a layer of thick membranous structure. The small intestine surrounded by fibrous membrane is disorder, tortuosity, aggregation, and fixation. The fibrous membrane may be enhanced by contrast enhancement scanning. In this study, it was easy to be misdiagnosed for the difficulty to distinguish the envelope sign due to extensive adhesion between fibrous membrane and intestinal wall. In combination with a literature review, MR examination revealed circular low signal in the center and annular iso-intensity in the periphery on T1WI and uniform circular or oval low signal on T2WI. PLB should be differentiated as followings: calcification of the aneurysm, calcified lymph nodes, urinary calculi, fecal stones, and uterine fibroids calcification and other pelvic high-density nodules. Free mobility is an important feature of PLB in the diagnosis of other pelvic high-density nodules. In addition, no enhancement is helpful for the identification of PLB.–7The most common imaging manifestation of PLB is the oval mass with central calcification and low-density area. Plain abdominal radiograph shows round or oval calcified mass in the pelvic cavity, which can move freely. CT is an important examination method for preoperative evaluation and differential diagnosis of PLB. CT examination showed concentric circle or oval mass with central calcification and peripheral soft tissue density, and often the mass would have a distinct fat plane separating it from adjacent organs.AC and PLB are both rare clinical diseases. In this case, the possible relationship of AC and multiple PLB is ischemia, necrosis, and abscission of some greater omentum adipose tissue in the forming process of intestinal fibrous capsule. On the other hand, multiple factors of AC stimulate peritonitis and prompt a large number of fibrin deposition, leading to the formation of PLB.Imaging findings and related clinical symptoms of AC and PLB should be understood and recognized by radiologists and clinicians to establish the correct diagnosis and treatment plan.


This is the third reported case of a steatocystoma simplex in the lacrimal caruncle.A 60-year-old male presented with a history of a slowly progressing mass in the right lacrimal caruncle since several years before his initial visit. At the first examination, a yellowish, relatively smooth surface mass was observed in the right lacrimal caruncle. The caruncular mass was completely removed under local anesthesia. The pathological findings of this mass were consistent with a steatocystoma. At the 6-month follow-up, there was no sign of recurrence or development of the steatocystoma or any other masses.Although steatocystoma simplex rarely occurs in the lacrimal caruncle, it needs to be considered as a possible diagnosis for patients with a mass lesion in the caruncle. Steatocystoma is a benign tumor thought to be a circumscribed malformation arising from the pilosebaceous duct junction . SteatocIn this case report, we present a case of a steatocystoma simplex in the lacrimal caruncle.This study was approved by the ethics committee of Aichi Medical University Hospital (No. 2015-H011) and adhered to the tenets of the 1964 Declaration of Helsinki. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.A 60-year-old male presented with a history of a slowly progressing mass in the right lacrimal caruncle since several years before his initial visit. There was no family history of any similar masses. The patient had no history of removal of any similar masses.At the first examination, a yellowish, relatively smooth surface mass was observed in the right lacrimal caruncle Fig. . The patAll three lesions were completely removed under local anesthesia without rupture. The cysts were not opened prior to histological processing. The pathological examination of the caruncular mass revealed a cyst lined by squamous epithelium Fig. . The cysWe describe a case of a steatocystoma simplex in the lacrimal caruncle. Although 962 cases of lacrimal caruncular tumors have been previously reviewed in eight reports, none of them included steatocystomas –15. OnlyThe steatocystoma simplex is a cutaneous tumor thought to be a circumscribed malformation arising from the pilosebaceous duct junction . As the Differential diagnoses of the steatocystoma simplex in the lacrimal caruncle vary. An oncocytoma is a slowly progressing, cystic mass; however, it usually exhibits a reddish-blue tan color . AlthougIn conclusion, we present a rare case of a steatocystoma simplex in the lacrimal caruncle. Steatocystoma simplex therefore needs to be considered as a possible diagnosis for patients with a mass lesion in the caruncle.


Cutis verticis gyrata (CVG) is a benign proliferation and hypertrophy involving the scalp which exhibits furrows resembling the cerebral cortex convolutions. The diagnosis of CVG is based on clinical findings. Complementary investigations are recommended to rule out local or systemic underlying disorders.Idiopathic or essential primary CVG refers to cases without obvious origin and with no other associated abnormalities. These forms affect mainly men. Herein, the authors present a new observation of an idiopathic CVG in a female, which seems to be extremely rare. First described by Alibert in 1837 , 3, is aA 36-year-old female with no significant medical history was referred to our consultation for a scalp thickening that was steadily evolving for nine years. Maceration and pruritus were the patient’s main concerns. Hairdressing became tricky and the patient also reported cosmetic concerns. No similar cases in the family were to be disclosed.The clinical examination found a soft and painless thickening of the scalp made of cerebriform convoluted folds and furrows, more conspicuous in the parietal and the occipital regions Figure .Otherwise, the patient appeared healthy. A punch scalp biopsy was then performed and did not reveal any inflammatory or neoplastic disease.Blood screening tests including glycaemia, thyroid hormones, and growth hormone were all within normal ranges. Antinuclear antibodies and syphilis screening tests were negative.Except for the scalp thickening, the computed tomography (CT)-scan of the head did not show any cranial or cerebral abnormality.In the light of these findings, the diagnosis of idiopathic CVG was raised. The patient was then admitted to the operating room for a partial surgical excision of the scalp under general anesthetic with oro-endotracheal intubation. She was laid down in a prone position to allow for easy access to the occipital extension of the scalp deformity. After the skin tension direction was checked and the tracing was made, about 50 mL of normal saline solution (0.9%) with epinephrine (0.4 mg) was infiltrated in the subgaleal and subcutaneous planes. An elliptical excision was carefully performed along the anteroposterior axis Figure . The incSince 1953, CVGs are classified into two main groups: secondary and primary .Secondary CVG occurs as a consequence of conditions that produce pathological changes in the scalp structure . SeveralPrimary CVG refers to cases with no underlying cause. Garden and Robinson  subclassThe present paper reports the occurrence of an idiopathic CVG in a female patient which is extremely rare. To our knowledge, only one similar case  has beenAsserting the diagnosis of CVG is based on clinical findings. However, complementary investigations such as skin biopsies, blood tests, and radiology examinations are recommended to distinguish between secondary and idiopathic forms of CVG. Histopathologic features of primary CVG range from normal skin structure to thickened connective tissue with hypertrophy or hyperplasia of adnexal structures .Idiopathic CVG can be managed in different ways depending on the severity of the condition and the patients’ concerns. Abstention can be recommended for minor subclinical forms . The medSurgery remains the best option for patients who experience complications such as maceration or infections and for those who express major psychological or cosmetic concerns. The surgical approach consists of a scalp reduction surgery. Some authors support the use of tissue expansion before the scalp reduction surgery  while otIn summary, because idiopathic CVG occurs exceptionally in women, it is recommended to rule out secondary forms. Good hygiene and surgical excision remain the adequate solution in complicated or advanced cases with important cosmetic and psychological prejudice.


Malignant optic gliomas are rare, but they rapidly become lethal visual pathway tumors. We present the clinical course, treatment, and prognosis of a case of unilateral malignant optic glioma in a young man with a history of brain glioblastoma multiforme (GBM).A 21-year-old man, who had GBM 7 years ago complained of a transient shadow in his vision and presented with normal visual acuity but optic disc edema and an enlarged blind spot in the right eye . Magnetic resonance imaging (MRI) showed a right intraorbital optic nerve tumor without a brain lesion. Chiasm involvement and severe vision deterioration occurred 3 months later. A biopsy of the right optic nerve revealed glioblastoma. Concurrent chemoradiotherapy (CCRT) prevented involvement of the fellow eye 1 year after symptom onset.This report demonstrated that a regular ocular exam should be recommended for several years after GBM. In young healthy patients who are able to undergo chemotherapy and radiotherapy, visual function in the fellow eye can be preserved. Glioblastoma multiforme (GBM) is the most frequent and lethal type of malignant primary brain tumor in humans, and it has the poorest prognosis with a median survival of generally < 1 year from the time of diagnosis . GBM is Malignant optic glioma is rare and was first defined by Hoyt et al. in 1973 . It is aThe 21-year old man was diagnosed with brain GBM at 13 years of age Fig. , b. AfteHowever, at 11 months after symptom onset, brain MRI showed a right optic nerve tumor extending to the optic chiasm with progression in size (Modified Dodge classification : 2b R/L)  Fig. 2k2k, l. HeOne year after symptom onset, BCVA and VF were within the normal range in the left eye  and no recurrence or metastasis was noted in the latest follow-up brain MRI.GBM is a highly malignant brain tumor with a poor prognosis. GBM constitutes approximately 17 and 6.5% of intracranial neoplasms in adult and pediatric populations, respectively , 11.Currently, standard care to improve GBM patient survival begins with surgical removal followed by radiation and chemotherapy . DespiteThe most common tumor of the optic nerve is optic nerve glioma, which represents approximately 66% of all primary optic nerve tumors. Approximately 90% of optic gliomas occur in children and most cases are relatively benign . MalignaNeuroradiologic findings are unspecific and typically described as contrast enhancement and thickening of the optic nerve, chiasm, or tract, with lesions having hypo- to iso-intensity on T1-weighted images . BiopsieThe current standard therapy consists of surgical resection or biopsy as feasible, followed by radiotherapy and/or temozolomide chemotherapy for high grade astrocytomas , 21. TheOur case was challenging; diagnosis was difficult before biopsy because the optic nerve tumor appeared 7 years after brain GBM and visual function was initially normal. In addition, the complications of radiotherapy were a concern. The relationship between delayed radiotherapy and the progression and extension of the optic nerve tumor was unclear. Fortunately, BCVA and VF in the fellow eye remained unchanged despite the chiasm becoming involved 1 year after the symptom onset. Compared with previous reports, the progression of the optic malignant tumor was slower and the prognosis was better.In summary, malignant optic tumors may appear >5 years after brain GBM. Regular ophthalmic examinations and brain MRIs are recommended for early diagnosis. Additional studies should evaluate the role and optimal timing of early adjuvant radiotherapy before visual function decreases. Young age, good health, and the ability to undergo CCRT can palliate the clinical course and preserve visual function in the fellow eye.


We present a case of ulcerative colitis (UC) in a patient during the first severe relapse with colonic dilatation and coexisting of giant renal tumor. Kidney tumor was constricting on colon and imitating toxic megacolon (TM). The patient with severe acute colitis (SAC) was admitted to the Department of Gastroenterology and Hepatology with inflammatory bowel disease (IBD) diagnosed in the previous month, based on clinical symptoms, endoscopy, and histopathology results. Computed tomography (CT) revealed a giant left kidney tumor without evidence of infiltration, a dilatation of the transverse colon up to 6 cm, and narrow light of the descending colon. There were no signs of intestinal obstruction or perforation. The control X-rays revealed maintaining megacolon, with dilatation of splenic flexure projection up to 6.5 to 7.5 cm. The patient was treated conservatively with no apparent improvement and finally operated on. Intraoperatively, a large tumor of the kidney (12 cm) constricting intestine was revealed. Left-sided nephrectomy and partial resection of the colon with the emergence of a colostomy was performed. The histopathology exam revealed renal mucinous tubular and spindle cell carcinoma (RMTSCC), a very rare malignant kidney tumor of low malignant potential and relative good prognosis. It was identified in the past 20 years. To date, approximately 100 such cases of cancer have been described.Kukulska M, Smola I, Halon A, Paradowski L, Poniewierka E, Kempinski R, Annabhani A. A Case of Severe Ulcerative Colitis with Colonic Dilatation caused by Renal Mucinous Tubular and Spindle Cell Carcinoma. Euroasian J Hepato-Gastroenterol 2016;6(2):190-193. Prolonged conservative treatment increases the risk of complications. Sometimes urgency surgical treatment is needed as a life-saving procedure.1Ulcerative colitis (UC) is a chronic and diffuse inflammation of the colonic mucosa. The disease proceeds with periods of exacerbation and remission. Severe acute colitis (SAC) occurs in 12 to 25% of cases. All patients with SAC should be hospitalized. According to the European Crohn’s and Colitis Organization (ECCO) criteria, SAC is defined as the presence of six or more loose stools with blood per day (mandatory criterion), tachycardia (>90/min), elevated temperature (>37.8° C), anemia (hemoglobin concentration <10.5 gm/dL), or increased erythrocyte sedimentation rate (ESR) >30 mm/hour. The treatment of choice is steroids administered intravenously. Endoscopic procedures should be avoided, and laxative-based bowel preparation formulas should be used with caution as they are risk factors for the development of toxic megacolon (TM).2We present a case of patient with SAC with symptoms of TM confirmed in the computed tomography (CT) and several X-rays. The diagnosis process also revealed left kidney tumor constricting the large intestine and causing distension of the proximal colon, as determined during surgery. Nephrectomy and partial resection of descending colon and sigmoid junction, with emergence of colostomy, was finally performed. The histopathology exam revealed renal mucinous tubular and spindle cell carcinoma (RMTSCC) which stand for a very rare malignant kidney tumor, identified in the past 20 years, of low malignant potential and relative good prognosis.A 53-year-old male with UC and coexisting renal tumor, after embolization of left renal artery and with planned nephrectomy, was admitted to the Department of Gastroenterology and Hepatology in December of 2014 due to abdominal pain, fever, tachycardia, and severe diarrhea with bloody stools.Ulcerative colitis was diagnosed in November 2014, during hospitalization in the Department of Surgery, where the patient was treated for permeable intestinal obstruction. In the performed incomplete colonoscopy, coaxial inflammatory infiltration with accompanying diverticulum was visualized in the descending colon. Moreover, in the descending colon, sigmoid colon and rectum advanced lesions corresponding with UC were described. Histopathological examination confirmed the diagnosis.Clostridium difficile, Salmonella, Shigella, Yersina, Campylobacter, and enterohemorrhagic Escherichia coli (EHEC) infection.Blood test performed on admission revealed iron-deficiency anemia with a hemoglobin level of 10.4 gm/dL, raised inflammatory markers , and low cholesterol. Due to decreased albumin, the patient received human albumin solution. Stool tests ruled out Computed tomography, except with active inflammatory lesions extending from transverse colon to rectum, revealed dilatation of transverse colon up to 6 cm. There were no signs of intestinal obstruction or perforation. Within the lower pole of the left kidney, CT revealed the huge, mostly heterogeneous, well-bounded tumor size 7 × 9.5 × 10 cm . There wThe patient was treated with intravenous antibiotics (ciprofloxacin in combination with metronidazole), hydrocortisone, and fluids. He also received anticoagulant and masalazine. Despite of intensive treatment and parenteral nutrition, abdominal X-rays showed no sign of improvement. Progression in the dilatation of transverse colon up to 7.5 cm was visualized. We decided to transfer the patient to the Department of Surgery, where he was treated surgically. Intraoperatively, kidney tumor was found as the cause of the obstruction and dilatation of the colon. Nephrectomy and partial resection of descending colon sigmoid junction, with emergence of colostomy, was performed.The histopathology exam revealed RMTSCC with low malignancy potential, showing no mitotic activity, and with size of 12 cm diameter . NeoplasIn March 2015, the patient was admitted to the Department of Gastroenterology and Hepatology again due to fever, anemia and elevated inflammation markers. The CT images have raised suspicion of abscess in tumor bed and between bowel loops. The patient was treated surgically once again. During surgery, the abscess, however, was not confirmed. Still there was a progression of inflammation of the colon; so colectomy, appendectomy, and partial resection of ileum were performed.3 Forty percent of patients with TM or fulminant colitis require urgent surgery.4 Toxic megacolon can be also a complication of any kind of intestinal infections , ischemic colitis, radiation, or obstructive colorectal cancer.56 The pathophysiology of toxic colonic dilatation is poorly known.5 It is possible that myenteric plexi is involved in its development, causing paralytic dilation of the bowel.4Toxic megacolon is total or segmental nonobstructive colonic dilatation of at least 6 cm. It is a rare but serious complication that occurs among 1.6 to 3% of UC patients, usually during the first severe relapse with involvement of the left half of the colon or pancolitis.4After 48 hours of ineffective conservative treatment of MT, an urgent colectomy should be considered. In the case of urgent indications, and in patients with serious condition overall, procedure should be performed in two stages. Subtotal colectomy with preservation of the rectum and temporary ileostomy is a standard practice. In the second stage, restoration of intestinal continuity with ileal pouch-anal anastomosis (IPAA) should be considered.In our case report, SAC with coexisting big kidney tumor (12 cm diameter) was shown. They were accidentally identified at the same time during hospitalization of the patient in the Department of Surgery. It did not seem that renal tumor in any way influence the UC and induce complications. In CT scans and ultrasound of the abdomen, there were no signs of constricting the intestinal. Tumor was well demarcated without evidence of infiltration beyond the kidney. Therefore, the patient had embolization of tumor artery firstly and qualified for surgery to remove a kidney tumor urgently after control of exacerbations of inflammatory bowel disease (IBD).The patient was finally operated due to progression in the dilatation of transverse colon. Left-sided nephrectomy and only partial resection of the colon with the emergence of a colostomy was performed. It was not necessary to perform colectomy, which was favorable for the patient.7 To date, approximately 100 cases of cancer have been described. It occurs four times more in women than in men, in a wide range of age between 20 and 81 years.8 The size of the tumors recently reported varies between 1 and 18 cm.2 An association with nephrolithiasis has been noted.9 The prognosis for RMTSCC with classic morphology is usually good. Surgical excision  in most cases is a sufficient treatment; however, a close follow-up should be considered.7 Actually, to our knowledge, there are no reports of coexistence RMTSCC with IBD.The histopathology exam revealed RMTSCC. Renal mucinous tubular and spindle cell carcinoma is a rare type of renal cell carcinoma. It has been described as a distinct entity in the 2004 World Health Organization (WHO) tumor classification.Our case shows that megacolon was not a direct complication of the disease, but mechanical compression of the intestine by a kidney tumor. This shows the importance of difficulty in differential diagnosis and management. In conclusion, it is important to consider that the colonic dilatation can be caused by oppressive from the outside, even in a patient with SAC. In such a patient, high-risk emergency colectomy can be avoided. Therefore, the implementation of CT in patients with an unusual course of the disease is worth considering.


Neuroendocrine tumors (NETs) are heterogeneous neoplasms that originate from cells with a secretory function. Small bowel NETs (SB-NETs) are related to serotonin hypersecretion which causes: flushing, diarrhea, abdominal pain, bronchoconstriction and heart involvement, also known as carcinoid syndrome (CS). CS can be confused with an allergic reaction and thus should be considered as a differential diagnosis in the allergy consult. We present the case of a pediatric patient initially referred under the suspicion of food allergies.We present the case of a 17-year-old male with evanescent non-pruriginous erythematous lesions- flushing that appeared with food consumption, associated with conjunctival injection, warmth and diaphoresis after the lesions disappeared. He denied abdominal pain, diarrhea, cough or wheezing. The 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) excretion was elevated. The CT scan showed thickening of the distal ileum and multiple lesions on both hepatic lobules and the colonoscopy revealed a tumor in the ileocecal valve. Hepatic and intestinal biopsies reported a well-differentiated NET of the ileocecal valve with hepatic metastasis. He was started on octreotide and underwent a wide hepatectomy and right hemicolectomy with improvement of symptoms.NETs can present as carcinoid syndrome , which constitutes vague symptomatology and represents a challenging diagnosis for physicians. They can be confused with an allergic reaction and the allergist should consider it as a differential diagnosis. Accurate diagnostic tests will help to diagnose NETs earlier and potentially prevent carcinoid heart disease, bowel obstruction, and improve quality of life and mortality in these patients. NETs are heterogeneous malignant neoplasms, which originate from cells with a secretory function within the neuroendocrine system . The medSB-NETs occur more often during the sixth and seventh decade of life , 15. TheThe diagnosis of SB-NETs at an early stage is often difficult because the primary tumors tend to be small and generally do not lead to symptoms . Upon diThe most commonly involved type of cells in SB-NETs are the enterochromaffin (EC) cells, which are in charge of producing and storing 5-HT (serotonin). This substance is released from EC cells by different stimuli like mechanical stimulation, nutrients and chemical stimulators such as acetylcholine (Ach) . In the To better understand CS, it is important to define flushing. It is the changes in cutaneous blood flow accompanied by reddening of the skin; it can be divided into episodic and persistent. Flushing tends to favor face, neck and upper torso, because of the relative increased volume of visible superficial cutaneous vasculature in these zones . DiffereNETs are challenging due to their unspecific symptoms , 34, 35.A 17-year-old male was remitted to the allergist because he presented evanescent, erythematous lesions with any food consumption. He had been seen by other specialists because of this symptomatology and given the relation between the occurrence of symptoms and food ingestion there was the suspicion of food allergies. Along with these lesions he also presented conjunctival injection, warmth and diaphoresis after the lesions disappeared. He stated circumstances like standing for a long time, valsalva and strong emotions also triggered the symptoms. He denied abdominal pain, diarrhea, coughing or wheezing.The initial physical exam was normal; no lesions were observed. While in consult we decided to trigger the symptoms. The patient was asked to eat; the first time he had coffee and a piece of chocolate cake. Nine minutes after the ingestion he presented an evanescent erythematous rash on the face, trunk and extremities Fig. , which lAs the patient only presented flushing, we considered carcinoid syndrome an unlikely differential diagnosis, because it usually includes abdominal pain, diarrhea, wheezing or bronchoconstriction. Also, carcinoid syndrome is related to the release of serotonin in NETs, which is an improbable pathology in a teenager. Nonetheless, during his workup the 24-h urinary sample of 5-hydroxyindoleacetic acid, a metabolite of serotonin, was 42.6 mg, reference value is less than 10 mg/24 h and serum chromogranin A was normal. It was unusually high taking into account the patient, as part of the preparation for this test, was avoiding drugs and foods with high serotonin levels such as avocado, walnuts, banana, pineapple, among others . TherefoTwo years later the follow up visits showed evidence the patient had tumor progression in his liver. This suggests that the octreotide was not sufficient to block the effect of the neuroamines produced by the tumor. Everolimus 10 mg p.o. daily was started in combination with octreotide LAR in an attempt to control symptoms and tumor progression. Also, with the evident progression of hepatic lesions, the patient has so far been taken to four radiofrequency ablations in order to counteract its growth. The Endocrine Service continues to follow this patient and based on current disease evolution, more interventions will most likely be needed.This case shows a differential diagnostic for flushing not usually considered by allergists, CS symptoms are vague and can delay the diagnosis , 36. GivFlushing of typical CS often involves the face, neck and upper chest . This caFinally, it is important to emphasize the fact that SB-NETs are extremely rare in children and because of this, they are seldom considered among the differential diagnosis of allergy-like symptoms, such as flushing. This report will help to expand the limited literature and promote the use of the available tools in the adult world within the context of young children . All thi


Para-duodenal hernia (PDH) represents rare clinical entities based on few literatures.We report five cases of Para-duodenal hernia, all occurring in male patients ranging from 34 to 75 years of age. The patients had varied manifestations presenting with abdominal pain with or without vomiting and nausea and with or without signs of intestinal obstruction. CT images showed cluster of dilated bowel segments with displaced mesenteric vessels at hernial orifice. Laparoscopic surgical approach was adopted, and the patients were discharged about a week later without further complications.We hope to raise awareness about the management of this rare clinical entity and the benefits of CT imaging and laparoscopic surgery as standard approaches. Para-duodenal hernias (PDH) have traditionally been considered the most frequent type of congenital internal hernia . Left paA 68-year-old man complained left middle abdominal pain for 10 days. The pain was paroxysmal without nausea and vomiting. It got worse after meals. He has a past medical history of chronic gastritis treated with regular proton pump inhibitor. He had laparoscopic cholecystectomy 2 years ago. The results of complete blood count, serum and urine amylase were within normal limit. Endoscopy showed chronic gastritis with bile reflux. His abdominal CT scan showed that a part of small intestine and its mesentery were folded together on the left side of the abdomen (Fig. A 34-year-old man complained about left upper abdominal pain for 24 h. The pain was paroxysmal accompanied with vomiting. His abdominal CT scan showed a fold, at the left upper abdomen, consisting of small intestine coiled with mesentery Fig. .Fig. 3TrA 68-year-old man complained about upper abdominal pain for 2 days. The pain was paroxysmal accompanied with vomiting. He was diagnosed with chronic gastritis 2 months ago and was treated with medications without any relief. His abdominal CT imaging showed part of the small intestine was folded Figs. , 6. He uA 75-year-old man complained about abdominal distention and pain for 13 h. The pain was paraumbilical accompanied with nausea and vomiting. His abdominal CT imaging showed that the jejunum was folded at the left abdomen Figs. , 9. He wA 40-year-old man complained about right abdominal pain for 11 h. The pain occurred suddenly without triggering factors. It was mild and intermittent. He has a history of laparoscopic cholecystectomy for one year. His abdominal X-ray showed a mass in the right upper quadrant of abdomen Fig. , 13. A dPDH also known as mesocolic hernias are congenital and derive from embryonary peritoneal anomalies and associated abnormal intestinal rotation . These pTherefore, based on our experience and current literatures, we believe that laparoscopic approach is the optimum treatment strategy for patients with paraduodenal hernia, especially in health centres with strong experience of advanced laparoscopic surgery. Patients with or without small bowel obstruction and hemodynamically stable are suitable to enjoy the benefits of laparoscopic approach. Computed tomography remains the gold standard of imaging modality for early diagnosis of this clinical entity. However, the limitation of our report is that the number of cases is small and hence, a concrete conclusion can only be drawn based on our experience so far.


Leiomyosarcoma of the head and neck is a rare cancer with high local aggressiveness. Radical surgery and adjuvant treatment offer the best chance for cure, nonetheless 5-years recurrence rate remains high. Despite international guidelines are available for soft tissue sarcomas, no recommendations are specifically endorsed for leiomyosarcoma of the head and neck, due to the rarity of its presentation and consequently scarcity of data on long-term outcome.A 50-year old woman, operated 10 years before for leiomyosarcoma of the nasal pit and with negative 5-years follow-up, was admitted to our ward for impairment of the hepatic function. Total-body CT scan detected multiple localizations at lungs, kidneys, pancreas, bones, muscles, lymph nodes and thyroid. The pathologic report after lung biopsy confirmed the diagnosis of metastasis from leiomyosarcoma and the patients was scheduled for first line chemo-radiotherapy.Despite adequate primary treatment, distant and disseminated metastatic disease may be not excluded in leiomyosarcoma of the head and neck. Soft tissue sarcomas (STS) are malignant tumors of mesenchymal origin, arising in connective tissue and extra-osseous connective tissue and representing about 1% of all adult cancers . When arDespite international guidelines are available for staging work-up and therapeutic option of STS , 5, due Accurate data on long-term outcome are lacking. The largest retrospective series on 130 patients with sarcomas of the head and neck reported a 68% 5-years metastasis free-survival, a local recurrence rate within 5 years of more than 50%. In nearly half of metastatic patients it is observed a concomitant relapse in the primary site, suggesting high local aggressiveness. The classical sites of distant dissemination are liver, bone, brain and skin .This article presents a case of a 50-year old woman with disseminated metachronous metastases of leiomyosarcoma diagnosed 10 years after being operated and treated with radiotherapy for a primary tumor of the nasal pit and with a negative 5-years follow-up.A 50-year old woman suffering from psoriasis underwent a radical resection of a leiomyosarcoma of the nasal pit in the year 2006 she was subsequently treated with 13.2 Gy/12 fractions of radiotherapy. In the year 2011 she completed a 5-years negative follow up. No cases of soft tissue sarcoma were noticed among her relatives.In April 2016 the patient was admitted to our surgical ward for the incidental finding of abnormal values of hepatic function laboratory tests: alkaline phosphatase 286 U/L; gamma-glutamyl transferase 621 U/L; bilirubin 0.8 mg/dL; AST 488 U/L; ALT 1248 U/L. Patient history revealed abdominal discomfort in the previous 4 months. For this reason she underwent an abdominal ultrasound that excluded pathological findings. She had no symptoms or signs of pancreatic exocrine or endocrine insufficiency and no weight loss.After admission, the patient repeated an abdominal ultrasound scan that showed dilation of the intrahepatic bile ducts and a solid hypoechogenic 4 cm mass of the head of the pancreas. She was then submitted to a total-body contrast-enhanced TC-scan with detection of multiple hypodense pancreatic lesions Fig. , bilaterThe biopsy Fig.  was consTo further explore the maxillary region, a magnetic resonance was prescribed with the evidence of an additional lesion at left supraclavicular lymph nodal region. We completed the oncological staging by a total-body PET scan, which confirmed the multiple metastases at lungs, kidneys and pancreas, multiple high-metabolic intensity signals at bones , muscles  thoracic lymph nodes, and thyroid gland.The patient was evaluated for oncological treatment at a referral center. She started radiochemotherapy with 6 cycles of anthracycline and dacarbazine, plus single-fraction 8 Gy on selected bone localization. At restaging with total-body enhanced CT-scan and total-body PET-CT scan, partial remission of the disease was observed, according to RECIST criteria [Leiomyosarcoma of the head is a very uncommon malignant disease, characterized by high local aggressiveness. Since the incidence of this type of neoplasm is low, all patients should be treated by multidisciplinary team at referral centers.It has been suggested that radical surgical resection followed by adjuvant chemoradiation or neoadjuvant local radiation with postoperative chemotherapy, may represent the best opportunities for cure, but so far no gold standard treatments and follow-up protocols have been clearly recommended for head and neck leiomyosarcoma .Our patient presented with disseminated metastatic disease. We initially hypothesized that it might origin by a new growth carcinoma. The pathologic report was edited after comparing the lung biopsy with the surgical specimen of the former leiomyosarcoma and in both cases similar morphologic and immunohistochemistry patterns were found. Despite the resection of the former leiomyosarcoma dated 10 years negative follow up, the rarity of the disease and its pathognomonic features at pathology suggested that a relapse of the previous malignancy might be more likely than a new primary tumor.Metastases from leiomyosarcoma have been commonly described following local recurrence and, in case of primary lesion at head and neck, distant relapse is usually detected in the cervical region or in the lungs , while nSuh et al.  recentlyLocal recurrences have been described up to 15 years after primary resection . SimilarIn conclusion, despite radical resection, adjuvant chemoradiation and accurate long-term follow-up, distant and disseminated recurrence of the disease may not be excluded in leiomyosarcoma of the head and neck. Since prompt multimodal treatment of metastatic disease may improve overall survival, the suggested 10-years follow-up should be fulfilled. The adequate timing to interrupt surveillance after resection and its cost-effectiveness need further investigation.


This report presents the first case of low-grade fibromyxoid sarcoma (LGFMS) arising from the vaginal wall  and draws attention to differential diagnosis of masses arising from the vaginal wall. A patient presenting with abdominal pain to emergency department was diagnosed to have an ovarian mass filling the Douglas space. At laparoscopy, the origin of the mass was identified as the posterior vaginal wall. After vaginal excision of the gelatinous mass, pathologic diagnosis revealed a rare tumor, LGFMS. We discussed the differential diagnosis of vaginal LGFMS. The specious benign appearance may end up with local recurrence or metastasis at an unpredictable time in the future. LGFMSs are mostly described as tumors of trunk and lower extremities. To the best of our knowledge there is no LGFMS of the vagina reported before, literature review revealed two vulvar and one ovarian LGFMS,3. This report aimed to present the first LGFMS arising from the vaginal wall and to draw attention to differential diagnosis of future masses arising from the vaginal wall.Low-grade fibromyxoid sarcoma (LGFMS) is a rare soft-tissue sarcoma that presents in subfascial planes as an isolated tumoral mass and it was first described by Evans in 1987A 36 years old woman presented with abdominal pain to emergency department of a private hospital. Her magnetic resonance imaging report revealed a 6 cm ovarian cyst . She was. Most of these cystic lesions are asymptomatic and are diagnosed during routine gynecologic examination and do not require any intervention. Malignant transformation of Gartner’s duct cysts are rare(4). Other cystic malignant lesions arising from the vaginal wall are also rare and include vaginal squamous cell carcinoma. Mesenchymal lesions of the vagina pose a diagnostic challenge to the pathologist and include leiomyoma, leiomyosarcoma, schwannoma, angiomyofibroblastoma, aggressive angiomyxoma, cellular angiofibroma, superficial myofibroblastoma of the lower female genital tract and gastrointestinal stromal tumors,7. A mass lesion in Douglas pouch with a similar clinical presentation to our case was reported as adenoma malignum. Differential diagnosis of mass lesions presenting in the lower parts of the vagina may also include cysts of Bartholin’s gland. In the differential diagnosis of most of the lesions immunohistochemistry was reported to have a limited role and the diagnosis mainly depended on morphology.Differential diagnosis of vaginal mass lesions includes cysts arising from müllerian remnants. Most of these cystic lesions are benign and they grow anteriorly towards bladder, but aberrant embryological development may leave remnants of Gartner’s duct anywhere in the vagina and Gartner’s duct cysts in posterior vaginal wall has been reported previously. The case presented here is of additional interest and importance because of its location. Previously LGFMS cases have been reported from vulva and ovary but this will be the first case reported to develop from the vaginal wall.The gynecological examination of our case was completely normal 14 months ago, but preoperative duration of LGFMS has been reported to range from 1 month to 25 years. They sometimes used adjunctive radiotherapy and chemotherapy. Our case has been recently diagnosed and operated, therefore we cannot give data regarding disease free survival, but previously reported deaths due to tumor recurrence occurred at a range of 3 to 42 years, also the author reported survival with tumor upto 70 years.The largest case series of LGFMS reported by Evans were treated with excision initially, local recurrences and metastases were also mostly treated by excisionIn conclusion, most of the mass lesions of vagina are benign lesions but malignancies including LGFMS must be remembered in the differential diagnosis. These tumors have a highly variable overall prognosis and avoidance of intraabdominal operation may affect survival.


The term phantom tumor may be used to describe a well-demarcated opacity resulted from pleural effusion. Phantom tumors are commonly associated with congestive heart failure causing transudative pleural effusion within pulmonary fissures. The figure may bring about inaccurate invasive diagnostic interventions. We report a heavy smoker patient with multiple phantom tumors in the right lung resolved with medical management. This case report provides records for a timely management of similar patients. Fluid collection in minor and major fissures of the lungs resulted from congestive heart failure or chronic renal failure, is not a common finding on chest roentgenograms. But proper diagnosis is essential to commence the appropriate treatment and avoid inaccurate interventions.This finding which is known as “phantom tumor” or “vanishing tumor” may be mistaken for lung mass or consolidation. Although it resolves with timely diagnosis and optimal treatment, previous experiments show that misdiagnosis may result in unnecessary lung biopsy or long-term antibiotic therapy ,2. ReporOur patient was an 80-year-old male with an established diagnosis of congestive heart failure, admitted to Shahid Madani Hospital affiliated to Tabriz University of Medical Sciences, with the chief complaint of exacerbation of dyspnea in the recent 10 days.A comprehensive history was taken which was compatible with the New York Heart Association (NYHA) Functional Classification of IV. He was a heavy smoker smoking approximately 50 packs/year and presented with dry cough and shortness of breath. An echocardiography revealed ejection fraction of 20–25%. The patient underwent treatment for decompensated heart failure and an external pacemaker was installed because of hemodynamically unstable bradycardia.Chest X-ray showed three mass-like opacities in the right lung . A pulmoDuring the visit by a pulmonologist, the patient was awake and oriented and vital signs were stable. Dyspnea improved after several days of diuretic therapy. Pulmonary sounds decreased in the base of both lungs. Subsequently, spiral chest computed tomography was performed for further evaluations . BilaterOptimal treatment for heart failure and full dose diuretic therapy were recommended as well as a repeated chest X-ray in the following days. Four days later, a chest X-ray was obtained revealing clearance of the lung field, confirming the diagnosis of phantom tumor .Phantom or vanishing tumor is a rare but well-known condition , 5. RecoAs described here too, these opacities may be more than one  and are The most commonly described appearance is a well defined homogeneous mass, occupying the transverse fissure or sometimes the oblique interlobar fissures. As also described in the present case, fluid loculation has been in the right side in the majority of previous reports . In patiPulmonary infarction, pneumonia, tuberculosis, lobe collapse, malignant mass or metastatic neoplasm, abscess, emphysema, cyst and arteriovenous aneurysm are the differential diagnosis for this radiographic finding. Such case reports can make the diagnosis easier for internists and prevent invasive, unnecessary and costly interventions.In conclusion, pleural effusion within pulmonary fissures may be presented as phantom tumor and a timely management will prevent unnecessary interventions.


Primary hepatic angiosarcoma is a non-epithelial malignancy derived from sinusoidal endothelial cells, accounting for approximately 1.8% of primary hepatic malignancies. Diagnosis of primary hepatic angiosarcoma is complicated by difficulties in the qualitative radiological assessment of these tumors. Prognosis is very poor due to local recurrence and distant metastasis after liver resection or liver transplantation (LT).This case report describes two patients with primary hepatic angiosarcoma who were diagnosed by histopathological examination of the explanted liver after LT. One patient had undergone living donor LT, and the other had undergone deceased donor LT. Neither showed evidence of malignancy on the pre-operative imaging tests.Hepatic angiosarcoma has a very high relapse rate after LT. Pre-transplant liver biopsy may be necessary to distinguish diffuse hepatic angiosarcoma from tumors of other origin in patients with cryptogenic liver failure. Cryptogenic liver failure remains an important cause of liver transplantation (LT) despite technical advances in imaging modalities and laboratory examinations , 2. HepaA 59-year-old female with esophageal varices and minor ascites visited a local hospital for abdominal pain. Blood tests revealed thrombocytopenia and mild liver dysfunction. She was negative for markers of viral hepatitis and autoimmunity, and her hepatic venous pressure was not elevated. Idiopathic portal hypertension was suspected. Ligation of endoscopic varices resulted in worsening of liver function. She was transferred to our hospital for living donor liver transplantation (LDLT). At admission, she was classified as Child-Pugh grade C with 11 points and her model for end-stage liver disease (MELD) score was 17. Abdominal contrast enhanced computed tomography (CT) revealed several small, low-intensity nodules in the liver but showed no definite tumors Fig. a, b. ImmA 43-year-old male visited a local hospital for abnormal liver function. Because his liver function was worsening, he was admitted to our hospital. Enhanced CT revealed hepatosplenomegaly. The contrast effect of the liver was blocky. No tumor in the liver was observed Fig. b. He wasAbout 2–3% of soft-tissue sarcomas in adults are angiosarcomas. Primary hepatic angiosarcoma is a rare malignancy, accounting for about 1.8% of all primary hepatic tumors and fewer than 5% of angiosarcomas , 7. The Liver biopsies are difficult to obtain from patients with cryptogenic liver failure. Nevertheless, pre-transplant liver biopsy may be necessary to distinguish diffuse hepatic angiosarcomas from tumors of other origin in patients with atypical cryptogenic liver failure.


Cholangiocarcinoma is a malignant disease of the epithelial cells in the intra- and extrahepatic bile ducts. It is the most frequent biliary malignancy. The lack of effective medical treatment makes a radical surgical resection the only therapeutic option. However, frequently Intrahepatic cholangiocarcinoma metastasize in lymphatic chains, including the hepatoduodenal ligament, and it often invades adjacent organs or metastasizes to other visceral organs such as the lungs, bones, adrenal glands, and brain and the prognosis remains poor. We present a case of elderly patient with a severe and progressive pain due to a pathologic fracture of humerus. The medical investigations revealed the presence of an intrahepatic cholangiocarcinoma. Cholangiocarcinoma (CCA) is a lethal cancer of the biliary epithelium, originating from the liver (intrahepatic), at the confluence of the right and left hepatic ducts (hilar) or in the extrahepatic bile ducts. It is a rare malignancy associated with poor prognosis. CCA is relatively uncommon with an annual incidence of 1 - 2 cases per 100,000 in the Western countries . CCA has2 at days 1 and eight, every three weeks. To reduce the strong pain the patient assumed opioids and he effectuated a palliative radiotherapy (30 Gy) on the bone metastasis.A 71-year-old man with a history of hypertension and diabetes both well controlled, medically and hepatitis C, presented a 2-months history of progressive and severe right homer pain, with asthenia and mild abdominal pain. On physical examination, the patient was not icteric, but had right upper quadrant abdominal tenderness. Hematology and biochemistry laboratory investigations revealed an alteration of liver function: alkaline phosphatase 879 IU/L; Alanine aminotransferase (ALT) 138 IU/L; aspartate aminotransferase (AST) 97 IU/L. The CA19-9 was mildly elevated to 43 .The rest of the other blood tests were within normal limitation. On orthopedic evaluation, X-ray of right shoulder showed an extensive osteolytic lesion of homer compatible with a bone metastasis. Bone scan confirmed the presence of lesion revealing an increased activity in right humerus . ComputeCCA is a lethal cancer of the biliary epithelium and can develop anywhere along the biliary tree. Intrahepatic cholangiocarcinoma is a malignant tumor arising from the epithelial cells of the intrahepatic bile ducts. Intrahepatic cholangiocarcinomas initially present as mass-forming lesions, and obstructive symptoms are rare. The only curative treatment available is surgical management. Unfortunately, many patients present with unresectable tumors, the majority of whom die within a year of diagnosis. In addition to the several well-known risk factors that contribute to CCA, recent studies have investigated the association of ICC with viral hepatitis infections; however their roles as risk factors in ICC development remain unclear. The major metastatic pattern for intrahepatic cholangiocarcinomas is early lymphatic spread. The hepatoduodenal ligament is the most common site for lymph node metastasis irrespective of tumor location. Metastasis is frequent and occurs to many organs, with 50% of patients at autopsy having hematogenous spread to the lung, lymphatic metastasis, and brain, and less frequent to the bone. Metastatic bone disease is common in patients with cancer and is a frequent cause of morbidity in advanced cancer patients. Most patients with bone metastasis suffer from pain resulting from structural damage, periosteal irritation, and nerve entrapment. Pain induced by bone metastases is frequent and difficult to treat because of its intermittent and progressive nature. Recent trial confirmed the benefits of ZA on pain and QoL also in elderly patients with bone metastasis from solid tumors . However


Small bowel obstruction is a common surgical emergency. The common causes are adhesions, malignancies, and hernias. We present a rare case of small intestinal obstruction caused by an enterolith in the distal ileum in a patient with an apparently normal gut. A 59-year-old male who underwent gastrojejunostomy 15 years back presented with features of intestinal obstruction of five days' duration. After initial conservative management, the patient was taken up for laparotomy. An enterolith causing obstruction was found in the distal ileum, and it was crushed and milked into the colon. The patient made an uneventful recovery. The chyme crossing the ileum is usually liquid or semi-solid and hence luminal obstruction by the faecal bolus in the ileum is very unusual. In patients with previous gastric surgeries where the pylorus is bypassed, the solid food particles enter the small intestine and can form a bezoar. This patient was managed with laparotomy and milking of the stool bolus into the colon. Other treatment options include enterotomy or resection of the diseased bowel and removal of the enterolith. Small bowel obstruction due to an enterolith is very rare and can pose a diagnostic challenge.  Small bowel obstruction is one of the common surgical emergencies we see in our day-to-day practice. Postoperative adhesions (60%) are the most common cause of small bowel obstruction, followed by malignant deposits or extrinsic compression of the small bowel by other primary malignancies (20%) and intestinal hernias 10%) [0% [1]. IA 59-year-old male presented to the emergency department with complaints of diffuse abdominal pain, vomiting, and abdominal distension for five days. He reported not passing stools for two days. He had an elective laparotomy done 15 years back for peptic ulcer disease in our institute, the details of which were not known. On examination, he was conscious, oriented, and his vitals were stable. His abdomen was soft and distended with exaggerated bowel sounds. On digital rectal examination, the rectum was empty. Plain x-ray of the abdomen did not show any evidence of acute intestinal obstruction. An ultrasound of the abdomen was done which showed dilated hyper-peristaltic small bowel loops of maximum caliber 3.5 cm. There was no free-fluid in the peritoneal cavity and the gall bladder was normal. A clinical diagnosis of the adhesive intestinal obstruction was made, and the patient was managed conservatively with intravenous fluids and nasogastric drainage. Following 48 hours of conservative treatment, the patient had clinical improvement and was started on oral fluids. After two days of starting oral feeds, the patient again developed abdominal distension with bilious vomiting. A water-soluble contrast study was done which revealed dilated jejunal loops with multiple air-fluid levels and slow filling of the contrast till the ileum [Figure In view of the persistent high nasogastric drainage of more than one litre a day and diffuse abdominal pain with guarding, the patient was planned for an exploratory laparotomy. Intraoperatively, there were no adhesions. A 6 × 5 cm well-defined firm intraluminal mass was palpable in the ileum about 45 cm proximal to the ileocaecal junction. The bowel loops proximal to the mass were dilated and the loops distal to it were collapsed Figures -3. The mThe postoperative period was uneventful. The patient was started on oral feeds on postoperative day two and was discharged on postoperative day six. On follow-up, an oral contrast study was done, which showed normal study of the bowel.Enteroliths are abnormal concretions occurring in the intestine and are usually composed of mineral salts . An enteEnteroliths are classified as primary enteroliths (that form within the bowel) or secondary enteroliths (that form outside the bowel and migrate to the intestine). Gall stones and renal calculi can erode into the adjacent bowel, resulting in secondary enteroliths.They are also classified as true or false enteroliths based on their chemical composition. True enteroliths are composed of substances normally found in the gut. Choleic acid stones, calcium stones, ammonium-magnesium phosphate stones, and hydroxy-fatty acid stones are examples of true enteroliths. False enteroliths are usually formed by substances that are not normally found in the gut. They include undigested bezoars, precipitation of insoluble varnish stones, concretions of chalk, lime or barium sulfate stones, and inspissated faecal stones.The most common factor involved in the development of an enterolith is stasis within the bowel as a result of altered endoluminal propagation and peristaltic functionality. Stasis occurs frequently at areas of intestinal diverticula, sites of intestinal anastomoses, Roux-en-Y sites, intestinal kinking (adhesions), incarcerated hernias, and at sites of intestinal strictures . The micThe presentation is usually non-specific with most enteroliths remaining asymptomatic. The enterolith tumbling through the bowel lumen can result in fluctuating subacute type of intestinal obstruction. They can also present as surgical emergencies like acute intestinal obstruction, hemorrhage, and bowel perforations. In the present case, the patient presented with features of acute intestinal obstruction due to the impacted faecal mass in the ileum that warranted a surgical management. An abdominal x-ray is usually the first investigation in a patient who presents with features of intestinal obstruction. Only one-third of the enteroliths are radio-opaque . Radio-oIn enteroliths less than 2 cm in size and without any luminal compromise, conservative management with serial abdominal examinations, nil per oral, and intravenous fluids along with nasogastric suctioning can be attempted. Most enteroliths pass spontaneously with the above management . EndoscoSurgical management is reserved in cases of large stones when interventional methods are not available and when expectant management fails. Digital fragmentation of the stone followed by manual milking of the smaller parts into the large intestine is successful in 50% of the cases . Hard enMost reported cases of enteroliths occur in pathologic bowels, as in diverticular diseases or inflammatory strictures. This is a case of an enterolith occurring in a normal small bowel, and the location of the enterolith  makes this presentation a very rare one. One possible factor in this patient is the presence of a gastrojejunostomy, which can cause under-processed food in the stomach to enter the jejunum directly and go on to develop into an enterolith.


Small bowel obstruction secondary to phytobezoars is an unusual presentation in surgery. We present a case of an elderly female patient with an insidious onset of abdominal pain, abdominal distension, and bilious vomiting diagnosed radiologically to be small bowel obstruction. Exploratory laparotomy revealed a trapped mass of vegetable matter in the distal ileum. She had enterotomy with primary closure for removal of obstructing ileal phytobezoars. Her postoperative recovery was uneventful. Bezoar is a general term that describes entrapment of a mass of materials of different sources within the lumen of the gastrointestinal tract. Phytobezoars comprise aggregates of indigestible plant materials and mucus which can be an unusual cause of intestinal obstruction. Small intestinal obstruction due to bands, adhesions, hernias, and tumours is more commonly encountered in surgical practice.Phytobezoars may account for about 0.4–4% of cases of acute mechanical intestinal obstruction although there is no real consensus on its exact incidence , 2. PredWe present a case report of an elderly female Nigerian with normal dentition who had surgery for an obstructing small bowel phytobezoar following ingestion of large amounts of vegetable matter. We also conduct a review of literature on the management of phytobezoars.78-year-old known hypertensive woman was referred from a Private Hospital to the emergency room of Lagos University Teaching Hospital with an insidious onset of colicky right lower abdominal pain of 6-day duration and recurrent copious nonprojectile bilious vomiting of 5-day duration. She last opened bowel 5 days before presentation. She had developed abdominal distension and anorexia since the onset of her symptoms. She had no history of weight loss or jaundice. There was a history of high intake of vegetables based on advice from her friends.Examination at presentation revealed an ill-looking elderly woman with a respiratory rate of 28 cycles per minute and pulse rate of 100 beats per minute. Her blood pressure was 157/100 mmHg. Her oxygen saturation (SPO2) was 98%. Her chest was clinically clear. However, her abdomen was distended. There was right lower quadrant tenderness but no guarding or rebound tenderness. Bowel sounds were hyperactive. Rectal examination was normal. A working clinical diagnosis of intestinal obstruction secondary to possible right sided colonic tumor was made.Her full blood count and white cell count, differentials, and platelets counts were within normal range. Her renal function was normal except for the finding of hypokalemia of 3.0 mmol/l.Computed tomography scan Figures  and 2 rePatient was resuscitated and optimized for surgery. Exploratory laparotomy revealed dilated small bowel loop with a compressible obstructing mass (transition zone) at 50 cm from the ileocecal junction. The small bowel loop bowel distal to the transition zone was collapsed . EnterotMechanical intestinal obstruction in the elderly is a common presentation and indication for surgical intervention in surgery. Common intraluminal causes include tumours, gallstones, and foreign bodies. Bezoar-induced intestinal obstruction is rare. Bezoar is described according to its component and the location within the gastrointestinal tract. Four major types of bezoars include phytobezoar , trichobezoar , lactobezoar (milk-curds), and pharmacobezoar (medications).Gastric bezoars are found commonly in patients with poor mastication, poor gastric motility, and previous gastric surgery. Small and large bowel bezoars are uncommon. Phytobezoars are the most common bezoars encountered in surgical practice and are usually made up of concretions of plant cellulose, mucin, pectin, tannins, and mucins derived from ingested fruits and vegetables. Plant materials can aggregate to form an impacted bolus of material within the gastrointestinal tract resulting in acute intestinal obstruction. Persimmon fruit phytobezoar is the most common type reported in a series . Our patClinical presentation in patients with phytobezoars depends on the type, location within the gastrointestinal tract, and presence of predisposing factors. Gastric bezoars can present with epigastric discomfort and nonspecific abdominal pains.Small bowel phytobezoar usually presents with abdominal pain and distension, vomiting, and constipation. The principal symptoms of small bowel phytobezoars reported in a review are abdominal pain 49–100%), epigastric distress (80%), and vomiting and nausea 35–78%). Features of small bowel obstruction were found in 94.73% of cases. Less common symptoms include sensation of fullness or bloating, dysphagia, anorexia with weight loss, and even gastrointestinal hemorrhage , 4. Thes9–100%, e–78%. FeaDiagnosing phytobezoar-induced small bowel obstruction can be challenging preoperatively. Plain abdominal X-ray showing evidence of mechanical small bowel obstruction can be seen in most patients but is not specific. Abdominal computed tomography (CT) scan is 90% sensitive and 57% specific in excluding other differential diagnoses of bezoar-induced ileus [Treatment options for phytobezoar can be conservative, medical, or surgical. Conservative approach may be reasonable if the presenting symptoms resolve while the patient is being resuscitated or prepared for a more definitive treatment. Endoscopic fragmentation and extraction as well as chemical dissolution and lavage have been used in the treatment of gastric bezoars. However, surgical intervention is often required in the management of small bowel phytobezoars. Both open and laparoscopic approaches are described in the literature. Samdani et al.  reportedDefinitive diagnosis of phytobezoars is often made at laparotomy. The most common site of impaction is the distal ileum at 50–70 cm proximal to ileocaecal valve . This isDistal ileal phytobezoars may be fragmented manually at laparotomy and milked into the caecum ; more ofSmall bowel phytobezoar is an uncommon cause of acute intestinal obstruction in the elderly with a virgin abdomen. Preoperative aetiologic diagnosis based on history and physical examination may be difficult. Plain abdominal X-ray and ultrasound findings are that of nonspecific small bowel obstruction. Abdominal CT scan is invaluable in excluding other differential diagnoses. Surgery is often required in resolving the diagnostic puzzle and for definitive treatment. Recurrence following treatment is common and can be prevented by appropriate dietary habits and control of underlying factors.


We describe the surgical management of a 58-year-old man with inflammatory abdominal aortic aneurysm (IAAA) following treatment with preoperative steroids. The patient was transferred to our institution for abdominal pain and fever. Contrast-enhanced computed tomography showed juxtarenal abdominal aortic aneurysm surrounded by dense perianeurysmal fibrous tissue. Under a diagnosis of IAAA, steroid therapy with prednisolone was initiated to control the perianeurysmal inflammation. It continued for 3 weeks with a decreasing dose schedule, with remarkable decrease in the soft tissue mass. The patient underwent elective surgery 21 days after commencing steroid therapy. During surgery, adjacent organs were adherent to the aneurysmal wall, but fibrotic change to the retroperitoneum was very limited. He recovered uneventfully, and was discharged on postoperative Day 10. Therefore, it can be concluded that preoperative steroid therapy could minimize the operative risk for IAAAs, and improve surgical outcome. Inflammatory abdominal aortic aneurysm (IAAA), characterized by marked thickening of the aortic wall with fibrous extension to the adjacent retroperitoneum and rigid adherence of adjacent structures to the aneurysm, is a relatively rare disease that occurs in 3–10% of all abdominal aortic aneurysms (AAAs) . MoreoveA 58-year-old man presented to a local hospital with a 5-day history of abdominal pain and fever. His medical history was unremarkable, with no hypertension or regular medications, but positive for active smoking. Plain computed tomography (CT) showed enlargement of the abdominal aorta and a surrounding soft tissue mass. He was transferred to our institution for further evaluation and treatment.Upon admission, the patient’s blood pressure was 135/72 mmHg, and he had low-grade fever at 37.4°C. Blood analyses showed a nearly normal level of white blood cells but elevated C-reactive protein of 20.1 mg/dL. Contrast-enhanced CT of the abdominal vessels showed a juxtarenal AAA  surrounded by dense perianeurysmal fibrous tissue (Fig. 2, MAQUET Cardiovascular LLC, San Jose, CA, USA] was anastomosed proximally to the infrarenal aorta and distally to the bilateral common iliac artery. This operation was performed in 197 min without transfusion.A midline laparotomy exposed the white-changed retroperitoneum. Adjacent organs, including the duodenum and the ileum, were adherent to the aneurysmal wall, but fibrotic change to the retroperitoneum was very limited. After proximal control to clamp suprarenal aorta and distal control to clamp bilateral common iliac artery were obtained in sites distant from the thickened parts of the juxtarenal AAA, the aneurysm was opened longitudinally. The anterior and lateral walls of the aneurysm were significantly thickened Fig. . A DacroHe recovered uneventfully, and postoperative contrast-enhanced CT revealed a patent graft and a decrease in the retroperitoneal mass Fig. D. HistopIAAAs are a variant of aortic aneurysms characterized by massive thickening of the aneurysmal wall and extensive fibrous adhesion to adjacent tissues and structures. Although rare, their operative mortality is higher than that for atherosclerotic aortic aneurysms, and optimal perioperative management consisting of preoperative medication and subsequent open surgery or endovascular repair is required.et al. [In their reviews, Walker et al.  identifiet al. . Biochemet al. .IAAAs are clearly distinguished from atherosclerotic AAAs by adhesion between aneurysmal wall and adjacent structures such as the duodenum, ileum, ureter and inferior vena cava. Preoperative steroid therapy is particularly effective in the surgical management of cases with IAAAs in which preoperative CT scanning demonstrates the aneurysm and the extremely thickened aortic wall with periaortic inflammation and fibrosis, the so-called ‘mantle-sign’, which makes the operation very challenging due to difficult adhesiotomy . In the et al. [An unsolved issue in the preoperative management for IAAAs is the absence of guidelines referring to steroid therapy, especially indication and initial dose. Steroids have a definite anti-inflammatory effect, which might be also implicated in inducing weakening of the aneurysmal wall, as mentioned by Sasaki et al. . Preoperet al. . FurtherTreatment of IAAAs via endovascular repair has become increasingly common in recent years. Compared to open repair, it is less invasive, and the risk of iatrogenic injury in the presence of perianeurysmal adhesions is low. However, the patient’s anatomy was unsuitable for endovascular treatment due to a short neck in this case. We suggest that preoperative steroid therapy is particularly useful when open surgery is the only option, as in the current case.


Surgical resection is the first choice for intralobar sequestration (ILS). A lobectomy is often performed, though we consider that a segmentectomy may be sufficient for benign cases if the sequestration is completely included within a segment.We treated a 36-year-old female diagnosed with ILS. Chest computed tomography (CT) revealed several cystic lesions with niveau formation and consolidation in left segment (S)10 without communication of the bronchus and abnormal artery branching from the descending aorta. We performed a sublobar resection of left S10 including sequestration through a thoracoscopic minimally sized incision. The sequestration had dark red appearance and was completely included in the S10. The boundary line of S10 was clear with inflation of the lung after cutting bronchus 10. The postoperative course was uneventful. Chest CT findings at 2 years after surgery showed good expansion of the residual left lower lobe with no consolidation and respiratory function were nearly the same as the preoperative condition.A thoracoscopic segmentectomy for ILS is a feasible and useful procedure for qualified cases, even in adult patients who had repeated inflammation. Surgical resection is the first choice for intralobar sequestration (ILS). On the other hand, a lobectomy is often performed because of several reasons. For example, it is considered that the adjacent normal lung have damage due to repeated inflammation associated with sequestration, and/or ILS, which most likely occur in young patients who have adequate respiratory function. However, in cases of benign disease, we consider that a segmentectomy may be sufficient if sequestration is completely included in a segment by minimally invasive incision. There are some reports of a segmentectomy for from an infant to adult, but a few especially with thoracoscopic approach. This is the report of a thoracoscopic segmentectomy of a left segment (S)10 in an adult patient.The patient was a 36-year-old female with no symptoms to reveal consolidation in the left lower lung shown by chest radiography performed as part of a medical examination, though the patient did report long-lasting cold symptoms like cough and sputum. Chest computed tomography (CT) showed several cystic lesions with niveau formation and consolidation in left S10 Fig. , withoutBecause of patient desire to preserve pulmonary function for future childbearing, we conducted a sublobar resection of left S10 including sequestration through a thoracoscopic minimally incision . The window, which length was 4 cm, was placed on middle axillary line in the fifth intercostal spaces, and three ports, two were 5 mm and one was 12 mm in size, were on the anterior axillary line in the sixth intercostal spaces and the middle and posterior axillary line in the seventh intercostal spaces. An abnormal artery was found inside of the lung ligament branching from the descending aorta Fig. , b. It wThe boundary line was clear when inflation of the lung was performed after cutting B10. The parenchyma was divided with a stapler.Operating time was 286 min, and blood loss was 100 ml. The chest tube was removed on postoperative day 3, and the patient was discharged soon thereafter. Macroscopic examinations of surgical specimens showed multiple cystic lesions with a boundary and elastic artery flow into that area (Fig. Pulmonary sequestration was initially reported by Pryce in 1946 [Chest CT findings are useful for diagnosis, as those can show cystic or consolidation areas with the abnormal artery mostly in the lower lobe. Importantly, three-dimensional CT findings can clearly reveal the vessel. Surgical resection is the first choice of treatment, because sequestration causes repeated inflammation even in asymptomatic patients. Generally, lobectomy is likely the most common procedure for ILS, because it is considered that complete resection of sequestration should be performed, and the border of normal part become unclear because surrounding tissues may be damaged due to repeated inflammation. Several reports of a lobectomy for thoracoscopic surgery have been presented –4, of whSeveral methods are available to detect the border between segments, such as selective inflation  or injecHowever, many textbooks show that standard operation for ILS is lobectomy; we think that a segmentectomy of minimum segment performed under a thoracoscopic approach is effective and useful for intrapulmonary sequestration and should be considered as one of the options for this disease.A thoracoscopic segmentectomy for ILS is a feasible and useful procedure in qualified cases, even for adult patients.


Many options are available in literature for the management of delayed reconstruction following calcanectomy. In cases of low-grade tumor lesions, conservative surgery can be considered. We describe a case of delayed reconstruction by calcaneal allograft after calcanectomy for low-grade chondrosarcoma. At 12-month follow-up, the patient had no pain; MSTS score and AOFAS score were satisfactory. Subtalar nonunion was observed with no secondary displacement or graft necrosis. The aim of conservative treatment for this patient was to restore normal gait with plantigrade locomotion and function of the Achilles tendon. Calcaneal reconstruction by total allograft is an alternative approach following calcanectomy for calcaneal tumors. We also discussed other options of calcaneal reconstruction. Delayed reconstruction is needed in rare cases, especially following calcanectomy. For example, conservative surgery can be considered in cases of low-grade tumors. The aim of this report was to make a functional assessment of delayed reconstruction of the calcaneus by total allograft and to discuss alternative treatments.A 58-year-old patient was referred to our University Hospital in June 2014 for a chronic wound of the left heel. Review of the patient's clinical history revealed total calcanectomy in 2007 with a cement spacer fixed by pins after bone cancer. Pathological examination showed a well-differentiated cartilaginous tumor with bone resorption and hyaline tumor matrix without myxoid reshuffle. Investigations were compatible with a low grade of calcaneal chondrosarcoma with involvement of the Achilles tendon .In January 2015, delayed allograft bone reconstruction was performed using total calcaneus with the distal extremity of the Achilles tendon  retrieveAt 12-month follow-up there were no signs of tumor relapse. The patient was pain-free and had returned to work , with anOttolenghi and Petracchi  and MuscLi et al. , 5, 6 reScoccianti et al.  and KurvImanishi and Choong  and ChouChondrosarcomas develop very slowly in the young adult with no overt symptoms. A study by the Mayo Clinic reported a survival rate of 89% at 10-year follow-up , and theEach technique had its specific problems with regard to fixation, soft tissue coverage, donor site morbidity, and functional recovery . The useSoft tissue coverage is not always necessary and the decision to use flaps depends on tumor invasion. Several authors recommend the use of mixed flaps (pediculated fibular , 5, 6 orTotal calcaneal allograft is an alternative treatment of low-grade calcaneal tumors. We describe its use in delayed construction by allograft following calcanectomy. At 12-month follow-up, our patient had satisfactory clinical and functional scores. However, long-term monitoring is required to assess allograft survival in this indication.


Proptosis, the forward protrusion of the eyeball, is a common manifestation of a wide variety of diseases inside the orbit and its spaces. Its diagnosis is usually a combined effort of the ophthalmologist, otolaryngologist, neurosurgeon, and radiologist. A clinical study of twenty-five cases with unilateral proptosis were studied in different age groups over a period of about 3 years under different headings like distribution, clinical features, radiological features, histopathological aspects, management, and outcomes of diseases. Proptosis measurement was done by simple/plastic ruler exophthalmometry, and diagnosis was made after a detailed clinical examination and ancillary tests. Treatment modality was decided based on radiological and histopathological examination reports, which included medical surgery, radiotherapy, and chemotherapy or a combination of all. In our study, most of the patients were in the age group of more than 60 years. The M : F ratio is 3 : 1. One case had a large proptosis of 18 mm above normal and 2 cases were as small as 3 mm. Diagnosis was mainly done by clinical features and confirmed by radiological and histopathological features. Most of them were treated medically  and the rest by surgery with a combination of radiotherapy/chemotherapy . Proptosis is described as an abnormal protrusion of the eyeball , and in The causes of unilateral proptosis are innumerable. The eye is a major crossroad for all the structures around it which help in its support and functioning, which when affected extends into the orbit causing proptosis. It can be the most dramatic of the orbital symptoms, especially if it has an acute onset.A clear knowledge of the aetiologies will help the ophthalmologist to suspect, diagnose early, and provide treatment.An attempt has been made to study the aetiology, clinical features, histopathology, and management of proptosis and its outcome.This is a retrospective record based on a clinical analysis of 25 cases of patients who presented to the eye outpatient department with unilateral proptosis during a period of 3 years. A detailed ophthalmological examination was done and a simple/plastic ruler was used to measure proptosis. Readings greater than 18 mm were considered as having proptosis [Demographic details, clinical presentation, investigation details, and treatment details were noted. X-rays, B-scan, CT scan, and MRI orbit were performed to confirm the diagnosis.In our study of 25 patients presenting with unilateral proptosis, the age of the patients were between 6 and 75 years, and most of them were in the age group of more than 60 years old (24%) as shown in 18 were males (72%) and 7 were females (28%).The minimum proptosis was 3 mm and the maximum was 18 mm above the normal. Most of the patients had a right-sided proptosis, that is, 13 cases (52%). It was axial in 15 cases and eccentric in 10 cases as in Headache and protrusion of eye were the commonest presented complains in these patients along with other complains like pain, defective vision, epiphora, and diplopia shown in The most common etiology seen in our study was inflammation with 8 cases of acute onset (32%), then there were 5 cases of orbital cellulitis (20%), 1 case of mucormycosis (4%), 1 case of orbital apex syndrome (4%), and 1 case of frontal mucocele (4%). Other causes include pseudotumours  References to ENT, neurosurgery, and oncology were given for any associated conditions. Diagnosis was confirmed clinically and with the help of CT/MRI scans. Scans helped in localising the lesions and gave an idea into the aetiology of the condition and in making a decision in the management of the patient. In tumours, histopathology reports after biopsy wherever possible confirmed the diagnosis.Inflammations (13) were medically managed with systemic antibiotics and steroids. 12 patients were surgically managed by orbitotomies or orbital exploration, depending on the site, out of which 4 cases were done by the neurosurgeon. Following surgery, 5 underwent radiotherapy and chemotherapy, as shown in No complications were seen in follow-ups.16 (60%) improved with no disease, 3 (12.5%) were with disease as status quo, 1 (4%) steadily deteriorated, and there was 1 (4%) mortality in the study period.Orbital pathology usually presents as proptosis. Symptoms reflect the orbital volume increase. Direction indicates the site of lesion . In compThere are very few studies available about unilateral proptosis which include all lesions giving rise to unilateral proptosis.The causes of adult unilateral proptosis may be a retrobulbar haematoma following trauma, inflammatory conditions like orbital cellulitis, an orbital abscess, usually following frontal or ethmoid sinusitis, a pseudotumour of the orbit due to a granuloma of unknown cause, an epidermoid or dermoid cyst, a mixed lacrimal tumour , or a haemangioma. Malignant tumours include malignant melanoma, carcinoma of the maxillary or ethmoidal sinuses invading the orbit, and meningioma of the sphenoid. Thyroid eye disease which is usually bilateral also can present as a unilateral proptosis in its initial stages , 5. PrimThe causes of unilateral proptosis in a child include retinoblastoma in the first 5 years of life and infective orbital cellulitis .The direction of exophthalmos may indicate the likely aetiology and site of lesion . Axial pTo evaluate and treat the patient with unilateral proptosis, an ophthalmologist must work closely with the ENT surgeon, neurosurgeon, and radiologist to ensure a successful outcome in each case.During the past few decades, advances in diagnostic instrumentation and surgical technique have helped to elevate the orbit to an anatomical area of great clinical interest. CT, MRI, and orbital echography have dramatically improved diagnostic accuracy and allowed a more careful therapeutic planning , 10. OrbAs regards the management, inflammatory cases and benign orbital neoplasms were most amenable to satisfactory treatment, medical or surgical, while malignant primary tumours if detected early could be eradicated with fair chances of success. Surgically, results were more encouraging in cases of retinoblastoma and lacrimal gland tumours than in other highly malignant and infiltrative growths where deep X-ray therapy was the only possible recourse for palliative and temporary improvement.Proptosis in many cases if undiagnosed and unexplained when deep in the orbit and left to fate is not advisable, so orbital exploration is necessary to clear the worry of the patient as well as the ophthalmologist . AnterioUnilateral proptosis is a multidisciplinary problem and requires collaboration of different specialties  of an op


Although involuntary movements of stumps are less frequent than phantom sensation or other neurological sequelae of limb amputation, they represent a phenomenon that has been known for many years. The pathophysiology remains unknown, but it seems to be related to damage to the peripheral nervous system. Treatment is not standardized, but antimyoclonic drugs seem to be useful. Although the most frequently described neurological sequelae of limb amputation are phantom sensations, the occurrence of involuntary movements of stumps is a phenomenon that has been known for many years, but they have not often been described Positive involuntary movements in amputation stumps are choreiform or myoclonic movements in the remaining limb after amputation. The pathophysiology has not been completely elucidated, but the condition appears to represent a variant in the spectrum of movement disorders induced by an injury to the peripheral nervous system We describe a 66‐year‐old Spanish patient whose past medical history included malignant fibrous histiocytoma of pelvis diagnosed 4 years ago. He underwent several operations for the resection of the tumor and left hemipelvectomy were performed due to a tumor recurrence.A few days after surgery, he developed involuntary movements of the pelvic stump, but pain or phantom sensations were denied by the patient. There were no other neurological symptoms and no relevant neurological past or family history, he was on no medications.Clinical examination showed rhythmic, short, spontaneous, and involuntary jerks of the stump  and somatosensory evoked potentials (SSEP) did not show any abnormalities despite the fact that the involuntary movements were occurring at the time of the test. Electromyographic (EMG) recording of muscle activity was not carried out because the involuntary movements resolved after 24 h to low doses of levetiracetam (500 mg bd).Whereas most reported cases of motor impairment after limb amputation are related to functional impotence, there are cases and series of cases that reported abnormal movements in amputation stumps Peripheral movement disorders such as myoclonus, athetosis, and dystonia have been infrequently described and poorly understood. The pathophysiology has not been completely elucidated. Some authors proposed that a neuroanatomical network linking the somatic and sympathetic nervous system with participation of substance P directly initiates the abnormal depolarization of anterior horn cells.Myoclonus is caused by the brief activation of one muscle, leading to a jerk of the affected body part. This activation can arise from the cortex, subcortical structures, spinal cord or nerves roots, and plexi. In cortical myoclonus jerks will be preceded by a cortical discharge, which can be frequently recorded on EEG, although sometimes this test has limited sensitivity, and very high amplitude cortical somatosensory evoked potentials are usually recorded.We assumed that the involuntary movements were a form of peripheral myoclonus on the account that EEG, SSEP and the imaging of the spinal cord were normal. Unfortunately, this assumption could not be backed up by EMG data.As the pathophysiology is unknown, the treatment is not standardized, although drugs to treat myoclonus seem to be useful. There are also cases in which pramipexole treatment led to a marked decrease in the episodes CGCF: wrote the manuscript. LMR and PON: participated in the diagnosis and treatment of the patient described. GMT: reviewed the manuscript and advised about scientific content.All authors have not any actual or potential conflict of interest.Video S1. Involuntary movements of the left pelvic stump.Click here for additional data file.


Long-term term survival in patients with pancreatic neuroendocrine tumors has been reported, even in patients with metastatic disease. Metastases to the spleen are extremely rare, but have been reported from a number of primary malignancies, such as breast cancer, lung cancer, melanoma and ovarian cancer. This is the first report of a splenic metastasis from a primary pancreatic neuroendocrine tumor.The patient presented as a 53 years old white male with anemia and fatigue. Physical examination revealed a left upper quadrant fullness and computed tomography showed a 24 cm left upper quadrant mass with multiple liver metastases, splenomegaly and a 1 cm mass in the spleen. Resection of the primary pancreatic tumor (T4N0M1) was accompanied by gastrectomy, splenectomy and resection of adherent bowel. The spleen contained a metastatic lesion 1.0 cm in diameter, consistent with a primary neuroendocrine tumor of the pancreas. This operation was followed 8 months later, by delayed resection of liver metastases. The patient receives monthly administration of somatostatin long-acting analogue and has undergone several ablations of liver lesions with percutaneous radiofrequency ablation as well as a second liver resection. The patient is alive seven years after initial presentation, with no evidence of disease on imaging studies.This is the first report of a splenic metastasis from a primary pancreatic neuroendocrine tumor. The patient initially presented with synchronous multiple liver metastases and a single splenic metastasis. After resection of the primary tumor and spleen, the patient has undergone aggressive cytoreductive surgery/ablation of liver lesions and somatostatin therapy with resulting long-term survival. Neuroendocrine tumors occur throughout the body, and have a variety of presentations and clinical characteristics. Pancreatic neuroendocrine tumors (pNETs) are particularly rare, representing only 1-2% of all pancreatic neoplasms, but the treatment of these lesions continues to evolve with improving results. NETs are classified separately from carcinoid tumors, in part based on location . The cli.Metastases to the spleen have been reported from a variety of primary tumors. They remain extremely rare, no matter what the primary lesion is. In a meta-analysis of 713 patients with splenic metastases, Lam reported 23% from breast cancer primaries, 20% from lung, 9% from colon/rectum, 9% from ovary and the rest from the stomach, prostate, and other organs . The repWe report the case of a patient who initially presented with a pNET with synchronous liver metastases and a single metastasis to the spleen. This is the first report of a metastasis to the spleen from a pNET.The patient presented as a 53 years old white male with anemia and fatigue. Previous history included no medications, distal left lower extremity venous thrombophlebitis 2 months prior, status post laparoscopic gastric Roux-en-Y bypass (for obesity and diabetes mellitus which had been untreated and resolved postoperatively) three years prior to presentation and a left ulnar nerve decompression nine years prior. Physical examination revealed no palpable lymphadenopathy, a fullness in the left upper quadrant and fecal occult blood positive stool. Laboratory studies showed a serum hemoglobin of 6 mg/dl. Computed tomography (CT) scan of the abdomen showed a 24 cm left upper quadrant mass with multiple liver lesions, splenomegaly and a 1 cm mass in the spleen  and an octreotide nucleotide scan showed no lesions outside the liver. Left lateral segmentectomy was performed with simultaneous resection of multiple hepatic nodules throughout the liver. All lesions were consistent with metastases from the previously resected primary tumor on histopathologic examination.The patient was discharged without complications, and continued monthly somatostatin therapy as well as periodic CT scans to evaluate recurrence. About one year after liver resection, a new lesion appeared in the liver which was treated with percutaneous radiofrequency ablation (RFA). The patient did well until 14 months later when multiple liver lesions appeared. A second liver resection was completed, including resection of nine nodules (<1 cm size) and RFA of two central liver lesions. It was felt that all lesions visible were treated at that time. Seventeen months later, another liver lesion appeared which was centrally located and treated with percutaneous RFA. An octreotide scan showed no evidence of disease. About 20 months later another central area in the liver was treated with percutaneous RFA.The patient is now seven-years status post resection of the primary lesion, treated with monthly administration of somatostatin long acting release 20 mg IM, and followed with periodic CT scans of the liver. Diabetes mellitus persists and is treated with insulin. At seven years, there is no evidence of residual disease in the abdomen, or within the parenchyma of the liver. He remains asymptomatic and is doing well. The patient’s clinical history is summarized in the Table Neuroendocrine tumors are rare, but their reported incidence has increased over the last decades, which is attributed to improved diagnostic modalities and surveillance , 7. In oIn a series of 46 patients with pNETs, 48% presented with loco-regional disease and 52% presented with metastases . All patThe impact of lymph node involvement on survival in patients with pNET was studied by Krampitz and colleagues . They foSomatostatin receptor scintigraphy is an important modality in the evaluation of these patients, and peptide receptor radionuclide therapy has shown promising results in the therapy of these lesions . TransplThe presence of splenic metastases is usually reported in the context of a pre-terminal event with multiple visceral metastases. In this patient, it is of interest that the single spleen metastasis was found at the initial presentation. The origin of the splenic metastasis is the subject of some speculation. In the spleen, it is believed that reticulo-endothelial create an unfavorable environment for the growth and survival of tumor cells , 7, 15. In patients with late appearance of splenic lesions, treatment may be futile but splenectomy may benefit patients who experience significant pain due to splenomegaly. Isolated splenic metastases were extremely rare in a series of 92 splenic metastases, representing just 4% of the lesions . In thatDespite an extensive review of the literature including multiple databases , there are no reports of patients with metastases to the spleen from pNETs. In one review of unusual locations for metastases from neuroendocrine tumors, there were no lesions metastatic to the spleen . MetastaThis is the first report of a splenic metastasis from a primary pancreatic neuroendocrine tumor. There are a number of interesting features in the present patient’s clinical history. The spleen metastasis in this patient was solitary and found at initial presentation, rather than as a pre-terminal event. This patient had no lymph node metastases at initial presentation which is unusual in the presence of liver metastases. This patient has undergone aggressive cytoreductive treatment and monthly administration of long-acting somatostatin analogue that have likely contributed to the continued survival of this patient.