Gastric outlet obstruction usually presents with non-bilious vomiting, colicky epigastric pain, loss of appetite and occasionally, upper gastrointestinal bleeding. Causes can be classified as benign or malignant, or as extra- or intraluminal. Gastrojejunostomy is a well-recognised surgical procedure performed to bypass gastric outlet obstruction. A bezoar occurs most commonly in patients with impaired gastrointestinal motility or with a history of gastric surgery. It is an intestinal concretion, which fails to pass along the alimentary canal.A 62-year-old Asian woman with a history of gastrojejunostomy for peptic ulcer disease was admitted to hospital with epigastric pain, vomiting and dehydration. All investigations concluded gastric outlet obstruction secondary to a "stricture" at the site of gastrojejunostomy. Subsequent laparotomy revealed that the cause of the obstruction was a bezoar.Many bezoars can be removed endoscopically, but some will require operative intervention. Once removed, emphasis must be placed upon prevention of recurrence. Surgeons must learn to recognise and classify bezoars in order to provide the most effective therapy. Helicobacter pylori eradication therapy, this benign cause has become less common. Andersson and Bergdahl reported [Gastric outlet obstruction (GOO) in adults is not a single entity; it is the pathophysiological consequence of any disease process that produces a mechanical impediment to gastric emptying. There are benign and malignant causes. In the past, peptic ulcer disease was more prevalent than malignant causes, currently, it only accounts for 5% of all cases of GOO . With threported  that 67%Bezoars, concretions of indigestible material in the gastrointestinal tract, have been known to occur in animals for centuries. The incidence of bezoars in adult patients has increased as a result of operative manipulation of the gastrointestinal tract. Although bezoars are often recognised radiologically, endoscopy provides the most accurate means of identification. Many bezoars can be removed endoscopically, but some will require operative intervention. Once removed, emphasis must be placed upon prevention of recurrence. Surgeons must learn to recognise and classify bezoars in order to provide the most effective therapy.We report a case of a 62-year-old Asian woman with a history of gastrojejunostomy, who was admitted to hospital with GOO secondary to a bezoar. We present the case, discuss management and review the literature.A 62-year-old Asian woman presented acutely to the emergency department with a 1-day history of colicky epigastric pain and postprandial vomiting. She had been tolerating only liquids rather than solid food for 2 months. There was no history of weight loss, but she did report early satiety and loss of appetite.This woman had a history of peptic ulcer disease over 20 years ago in Kenya. It had led to GOO requiring truncal vagotomy and gastrojejunostomy. In order to investigate the cause of her dysphagia and loss of appetite, she had undergone an upper gastrointestinal endoscopy 3 weeks before this admission. This showed inflammation and oedema at the anastomotic site of the gastrojejunostomy, but no evidence of obstruction or stricture Figure . She wasThe patient was clinically dehydrated on examination. She had a very thin body habitus. Her abdomen was soft, but mildly tender over her epigastrium. Succussion splash was demonstrated and a 10 cm × 8 cm mass was palpable just right of the umbilicus. Bowel sounds were scanty. There were no clinical signs for upper gastrointestinal bleeding.Her admission blood profiles were essentially unremarkable. There was no biochemical evidence of fluid shifts or dehydration. Plain abdominal radiograph did not show any diagnostic features. However, her erect chest radiograph showed an air-fluid level within a dilated stomach Figure .In view of the examination and chest radiograph findings, she had a nasogastric tube and urinary catheter inserted for gastric decompression and urine output monitoring, respectively. An urgent contrasted computed tomography of the abdomen was arranged. Meanwhile, the nasogastric tube successfully prevented further vomiting, and there was little drainage from it. She was commenced on intravenous omeprazole and fluid therapy.The abdominal computed tomography Figure  showed aThe patient provided consent for expedited laparotomy and relief of obstruction. Intra-operatively, the jejunum was found to be dilated from the duodenojejunal flexure to a large bolus obstruction. A conical mass suspicious of a bezoar was found measuring 10 cm in length, situated 20 cm beyond the gastrojejunostomy. The small bowel distal to this site was collapsed. Attempts to break up this hard bolus mass externally were unsuccessful. The bezoar eventually had to be removed in whole via an enterotomy. Careful examination confirmed that it was indeed a phytobezoar Figure .The patient had an uneventful recovery and was discharged home 1 week after surgery. Before discharge, she was seen by the dietician with regard to different types of fibre diet. She was also advised on the importance of longer mastication of food.A bezoar is also known as an enterolith, a concretion of foreign or indigestible matter found in the alimentary canal. There are two main types of bezoars: trichobezoar – a bezoar formed from hair and phytobezoar – formed by indigestible cellulose. Rarely, pharmacobezoars from masses of tablets are found.This was an unusual presentation of symptoms and signs of GOO secondary to a phytobezoar, in that this woman had already had a gastrojejunostomy to bypass previous GOO caused by peptic ulcer disease. The oedema seen in her upper endoscopy 3 weeks before admission may have been the result of a distal subacute obstruction. Postprandial non-bilious vomiting is the cardinal symptom of GOO, which may lead to electrolyte abnormalities. The frequency of vomiting puts patients at risk of aspiration pneumonia. Early satiety and better tolerance to liquid than solid food may represent gastric dilatation, which may be appreciated by succussion splash. Management includes identification of the cause and reversal of any complications of GOO such as metabolic alkalosis, electrolyte abnormalities, and aspiration pneumonia. Diagnosis can result from upper endoscopy or imaging studies.Regardless of the cause, 75% of all cases of GOO require surgical intervention . DefinitBezoars tend to be rare, except in patients with previous gastric surgery  or gastret al. [Delayed gastric emptying and abnormal gastric motility patterns were prominent in one series of patients with bezoars, suggesting that these events were the underlying factors . There wet al.  reportedMore evidence has since emerged supporting this theory. Another study  involvinAs discussed, patients with bezoars often present with symptoms and clinical or radiological signs of bowel obstruction. Dilated small bowel loops may be seen in plain abdominal radiographs. In one retrospective study, the abdominal computed tomography scan was declared to be the most useful imaging modality for detecting bezoars . The stuBesides obstruction and its associated complications, other complications of bezoars include ulceration, intussusception, and bowel perforation. Intraluminal bezoar is a serious condition, with a mortality rate as high as 30% being reported in a retrospective analysis of 34 cases . Early dBezoar induced bowel obstruction is uncommon and remains a diagnostic challenge. It should be suspected in patients with an increased risk, such as those with previous gastric surgery, poor dentition, mental retardation and a suggestive history of increased fibre intake. Computed tomography of the abdomen should be performed early in these at-risk patients presenting with symptoms of GOO or small bowel obstruction in order to reduce unnecessary delays before appropriate surgical intervention. Bezoar is a curable condition but can potentially cause significant morbidity and mortality.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.EL revised the manuscript and researched the case while LW supervised the ethical approval, patient consent, patient management and amendments to the manuscript. RB acquired patient information, designed and drafted the manuscript, sorted patient consent, carried out day-to-day management of patient and provided intellectual content to the discussion of this case report.


Glomus tumors are uncommon tumors which can occur anywhere within the gastrointestinal tract but have been shown to occur most commonly in the gastric antrum. On CT, these tumors demonstrate hyperenhancement which may help distinguish them from other gastric masses. Glomus tumors originate in the neuromyoarterial glomus, a specialized arteriovenous shunt that is abundantly supplied with nerve fibers to help regulate skin temperature . Glomus We present the case of a biopsy proven gastric glomus tumor evaluated utilizing multidetector computed tomography (MDCT) and multiplanar reconstructions, which to our knowledge have not been previously discussed in the literature. A 58-year-old female with a past medical history of gastroesophageal reflux disease refractory to medical therapy underwent a routine esophagogastroduodenoscopy that revealed Barrett's esophagus, gastritis, and a 2 cm × 2 cm submucosal mass in the gastric antrum. Endoscopic resection of the submucosal mass was attempted but the lesion could not be safely removed. Biopsies, however, were obtained. A CT scan was performed to characterize the mass.Dual phase abdominal CT and 3D CT imaging was performed utilizing a 64 slice MDCT  with 0.6 mm collimation. 0.75 mm slices were reconstructed at 0.5 mm intervals for multiplanar reconstructions. 5 mm slices were also reconstructed at 5 mm intervals for review on Picture Archive Computer Systems. Patient was administered 100 cc of intravenous contrast material , infused at a rate of 3-4 mL/s. Scanning delays were 25 and 50 seconds for imaging of the arterial and venous phases, respectively. Water was administered for oral contrast. The patient was imaged in the supine position. Multiplanar reconstructions were created. Images were reviewed by a radiologist with extensive CT experience.Initial interpretation of axial CT dataset did not report a gastric mass, presumedly related to the size of the lesion. Multiplanar reconstructions, however, did reveal a 1.7 cm well marginated solitary markedly enhancing mass in the gastric antrum . RetrospGlomus tumors, or glomangiomas, can occur anywhere within the gastrointenstinal tract, including the cecum. They, however, have been shown to occur most commonly in the first part of the gastric antrum . GlomangGlomus tumors are soft in consistency and tend to change in size and shape with compression and peristalsis. This makes accurate diagnosis by either esophagogastrodeudonoscopy (EGD) or upper GI series challenging and nonspecific . For thiThe CT appearance of gastric glomus tumors is described in the literature as demonstrating dense homogenous enhancement in the arterial phase with prolonged enhancement in the delayed phase –6. GlomuIn most of the cases reported, the tumor presents as a benign appearing gastric antral mass. Differential diagnosis considerations for hypervascular tumors in the stomach include similar appearing lesions such as gastrointestinal stromal tumor (GIST), arteriovenous (AV) malformations, carcinoid tumor, heterotopic pancreatic tissue, angioleiomyoma, and angiolipoma. These entities are difficult to differentiate based on clinical history and imaging findings alone, and in symptomatic patients, histopathologic evaluation is warranted. Glomus tumors of the stomach can have nonspecific imaging findings and a vague clinical presentation, making it challenging to both detect and differentiate from other disease entities. Given the potentially poor prognosis of some of these possible diagnoses, early detection and characterization is critical. Multiplanar reconstructions may be an effective adjunct in detecting gastric abnormalities that may elude diagnosis when axial MDCT sections are interpreted alone. As illustrated in this case, gastric glomus tumor should be considered when a hypervascular intramural gastric mass is detected on CT.


Telangiectatic adenoma is a new classification of a hepatic lesion. It was previously named telangiectatic focal nodular hyperplasia but it is in fact true adenoma with telangiectatic features. We report here a case of telangiectatic adenoma in a 72-year-old woman. The image features are lack of a central scar, a heterogeneous lesion, hyperintensity in T1-weighted MR images, strong hyperintensity in T2-weighted MR images, and persistent contrast enhancement in delayed-phase contrast-enhanced CT or T1-weighted MR images. It is a monoclonal lesion with potential of malignancy. The treatment of telangiectatic adenoma is surgery, the same way as hepatic adenoma. Focal nodular hyperplasia may be managed by clinical follow-up alone. Telangiectatic adenoma (TA), previously known as telangiectatic focal nodular hyperplasia, was recently redefined as a variant of hepatocellular adenoma (HA), based on molecular and genetic evidence. This redefinition has potential clinical relevance because telangiectatic adenomas must be as aggressively managed as hepatocellular adenomas. Here we describe a case of a female patient presenting with a liver mass which turned out to be TA, and discuss this new pathological entity and its differential diagnosis, with emphasis on interpretation of imaging results.® T4, 75 μg), an anti-hypertensive agent , an antiarrhythmic drug , and acetylsalicylic acid (200 mg). She reported use of oral contraceptives for over 30 years. She had no history of smoking, drinking, drug abuse or family history of liver disease.A 72-year-old asymptomatic woman presented to the clinic for a checkup. She had a history of cholecystectomy, hypothyroidism, and hypertension. She had been treated with thyroid hormone  of the upper abdomen Figure  showed aMagnetic resonance (MR) imaging of the upper abdomen showed different components within the lesion. T2-weighted images in the peripheral region showed a discrete heterogeneous hyperintense signal, while the central portion was hypointense. In T1-weighted images, the signal in the periphery of the mass was similar to the muscle signal and the center of the lesion showed a signal that was clearly hypointense. Although impregnation of both components began in the arterial phase, the peripheral region showed a stronger signal during the arterial and portal phases, followed by signal decay in the late phase due to relatively rapid washout, indicative of hypervascularization. The center of the mass was far more intense in the late phase, probably due to slow flow through the vascular components Figures .Surgery and pathological analysis revealed a hepatic segment measuring 17.5 × 14 × 8 cm and weighing 1200 g that contained a 15 × 9 cm brown tumor with ill-defined limits. The tumor had a gelatinous component and showed hemorrhaged, necrotic, and cystic areas. The final diagnosis was TA. The patient progressed well and she remains asymptomatic after one year of follow up.Focal nodular hyperplasia (FNH) and liver cell adenoma (LCA) are the most frequent benign epithelial lesions of the liver observed in young female patients using oral contraceptives. Although they are both benign, the management of these two types of lesions is radically different, consisting of clinical follow-up for FNH and surgical resection for liver cell adenoma ,2.FNH is the second most common benign liver tumor, occurring predominantly in young and middle-aged women ,4. The tFNH is usually asymptomatic and is often discovered fortuitously. A non-operative approach has been adopted by most hepatobiliary centers because there are no proven cases of malignant degeneration. Pain may sometimes be present, particularly in the case of a large tumor, but hemorrhage is very rarely reported . Unlike LCA is a rare hepatic tumor that is characterized pathologically by the benign proliferation of hepatocytes . These tLCA usually comprises a single nodule; more rarely, multiple nodules may be present ,11. In cBased on previous studies, it is now clear that the lesions previously named telangiectatic focal nodular hyperplasias are in fact true adenomas with telangiectatic features; hence they are now referred to as telangiectatic adenomas (TAs). This new classification is based on both morphological and molecular features, and takes into consideration the results of clonal analysis and gene expression studies. It should be emphasized that the new classification has clinical relevance; aggressive management of these cases should be considered. However, it remains to be established whether the clinical behavior of TAs, including the associated risk of malignant progression, resembles that of LCA more than FNH.TA is defined as a benign well-differentiated proliferation of hepatocytes in which vascular changes, including telangiectatic features, are prominent . Clonal Benign hepatic tumors represent a broad spectrum of regenerative and true neoplastic processes. Many of these tumors present with characteristic features in imaging studies. The new classification of TAs has clinical relevance because they must be aggressively managed in the same way as HAs, whereas FNH may be managed by clinical follow-up alone.FNH: focal nodular hyperplasias; LCA: liver cell adenoma; TA: telangiectatic adenomasWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.TCT conceived the study. RFC, FCC and RRB performed the literature review. TCT, AE, GZ and EM edit and coordinated the manuscript. All authors read and approved the final manuscript.


Acute megakaryoblastic leukemia (AMKL) is a rare subtype of acute myeloid leukemia. Although known as a distinct entity for a very long time, because of lack of distinct clinical features and morphological criteria, it is difficult to diagnose this variant correctly. We herein present the clinical, morphological, cytochemical, and immunocytochemical features of five cases of AMKL. Certain morphological features such as presence of abnormal platelet count, giant platelets, and cytoplasmic blebbing in blasts were found to be important pointers towards the diagnosis. However, none of the features were found to be consistent and thus morphological diagnosis has to be confirmed by cytochemistry and immunocytochemistry. Acute megakaryoblastic leukemia (AMKL) is a rare entity and accounts for 3–5% of all acute myeloidleukemia . AlthougAll acute megakaryoblastic leukemias diagnosed in the Department of Pathology of Lady Hardinge Medical College,New Delhi, in the period 1997 to 2007, were included in the study. A total of five cases wereretrieved. The clinical history and other details were taken from the casefiles.Wright'sstained peripheral smears and bone marrow aspirate (BMA) smears were examined. Bone marrow biopsy was available in only one case.Cytochemistry, including myeloperoxidase (MPO), Sudan black B (SBB), periodic acid Schiff (PAS), and nonspecific esterase (NSE), was available in all the cases.Immunophenotypingwas done in 4 out of 5 cases. In 3/4 cases, immunocytochemistry was done by APAAPtechnique using DAKO antibodies  and in tClinical and haematological profiles of our 5 cases are summarized in Tables Most of the cases were males (M:F = 4:1). Out of the 5 cases, two were adults while theother three were in the pediatric age group (1.5 years to 6 years).Four outof the five cases had an acute onset illness and presented with symptoms ofmarrow infiltration while the fifth patient had a long history of 3 yearsduration which is described separately.One patient out of these 4 cases had featuressuggestive of Down's syndrome (Case IV). Hepatosplenomegaly and lymphadenopathywere observed in two and one patient, respectively .All the four cases were anemic. Leucocytosiswas noted in 3 while one case showed thrombocytosis (Case II). Giant plateletswere present in Case I only.Peripheralblood blast count was in the range of 4% to 40%. The blasts were large, 3-4times the size of a small mature lymphocyte with moderate to abundant agranularbasophilic cytoplasm. The nuclei were round to oval with fine to stippled chromatin& 1-2 prominent nucleoli. Few blasts in all the cases showed cytoplasmicblebbing . PlateleBonemarrow aspirate smears were cellular in three out of four cases showing blastsranging from 25% to 56% of all nucleated cells with morphology similar to thatseen in the peripheral blood along with presence of micromegakaryocytes andpromegakaryocytes. In one of the cases, blasts showed clustering mimickingmetastases (Case I). In the fourth case (Case IV), repeated attempts of BMAyielded diluted marrow. Bone marrow biopsy in this case showed blasts withclustering and increased reticulin fibers (Grade III).The fifth case (Case V) had a long duration illness and presented with weakness andabdominal distension for 3 years.Thispatient had massive splenomegaly, 7 cm below costal margin and mildhepatomegaly. The patient was anemic with a normal total leukocyte count andplatelet count. Peripheral smear showed a leukoerythroblastic blood picturewith presence of tear drop cells and 25% blasts. Bone marrow aspirate revealed28% blasts. These blasts had morphology and cytochemical findings similar to thoseof the other cases . Based oAMKL is a rare leukemia, accounting for 7–10% of childhoodAML , 9 and cIt is difficult to diagnose this variant solely on the basis of morphology. However,there are features like clustering of blasts, presence of cytoplasmic blebbing,and platelet budding which may be useful in clinching the diagnosis . In ourThrombocytosiswas present in one patient who was a 22-year-old female while the other adultpatient had a normal platelet count. All the three pediatric patients werethrombocytopenic. This observation is similar to that seen in other studies ,thus emAMKL is a rare leukemia. It is important to correctly diagnose this variant in view ofits prognostic implications. Although immunophenotyping is the gold standard,it is not available in all the centers. Careful search for features likecytoplasmic blebbing, platelet budding, bone marrow fibrosis, clustering ofblasts, and cytochemical positivity for nonspecific esterase which is fluorideresistant can help in correctly diagnosing a significant number of AMKL.


Hemobilia is a rare but lethal biliary tract complication. There are several causes of hemobilia which might be classified as traumatic or nontraumatic. Hemobilia caused by pseudoaneurysm might result from hepatobiliary surgery or percutaneous interventional hepatobiliary procedures. However, to our knowledge, there are no previous reports pertaining to hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy.A 65-year-old male was admitted to our hospital because of acute calculous cholecystitis and cholangitis. He underwent cholecystectomy, choledocholithotomy via a right upper quadrant laparotomy and a temporary T-tube choledochostomy was created. However, on the 19th day after operation, he suffered from sudden onset of hematemesis and massive fresh blood drainage from the T-tube choledochostomy. Imaging studies confirmed the diagnosis of pseudoaneurysm associated hemobilia. The probable association of T-tube choledochostomy with pseudoaneurysm and hemobilia is also demonstrated. He underwent emergent selective microcoils emobolization to occlude the feeding artery of the pseudoaneurysm.Pseudoaneurysm associated hemobilia may occur after T-tube choledochostomy. This case also highlights the importance that hemobilia should be highly suspected in a patient presenting with jaundice, right upper quadrant abdominal pain and upper gastrointestinal bleeding after liver or biliary surgery. Hemobilia is a rare but lethal biliary tract complication . PatientA 65-year-old male was admitted to our hospital because of right upper quadrant abdominal pain, jaundice and fever for 2 days. He denied history of any systemic disease. He had no history of previous abdominal surgery. At initial presentation, his body temperature was 38.6°C, blood pressure was 142/82 mmHg, pulse rate was 92/min, and respiratory rate was 22/min. Physical examination revealed jaundice, and tenderness with light palpation at the right upper quadrant of abdomen. Murphy's sign was positive. There was no palpable mass and Courvoisier's sign was negative. The bowel sound was normal in peristalsis and no abdominal bruit was found on auscultation.3 , a hemoglobin level of 15.3 g/dL , and a platelet count of 22.3 × 104 /mm3 . The liver profile showed total bilirubin = 4.3 mg/dL , direct bilirubin = 3.2 mg/dL , alanine aminotransferase = 108 IU/L , aspartate aminotransferase = 103 IU/L , and alkaline phosphatatse = 327 IU/L . The serum levels of amylase and lipase were 166 U/L  and 208 U/L  respectively. Blood cultures were negative for aerobic and anaerobic organisms. Abdominal ultrasonography revealed a distended gallbladder with thickened wall and filled with stones. A small amount of ascites was detected in the Morison's pouch. The common bile duct (CBD) was mildly dilated with some hyperechoic spots, indicating sandy CBD stones.Laboratory studies demonstrated a white blood count of 10,800/mmBecause acute calculous cholecystitis and cholangitis were impressed on clinical grounds, he underwent cholecystectomy and choledocholithotomy via a right upper quadrant laparotomy. At operation, an inflamed gallbladder with fibrin coating on the edematous wall was found. The Calot's triangle showed dense adhesion and the CBD was distended. The CBD was explored to remove sandy stones, debris and sticky bile. A temporary T-tube choledochostomy was created and Penrose drains were set in the Morison's pouch.th postoperative days. However, on the 19th day after operation, he suffered from sudden onset of hematemesis and massive fresh blood drainage from the T-tube choledochostomy. Hypovolemic shock developed thereafter. He was sent to emergent department of our institution. Laboratory examination revealed a decreased hemoglobin level of 7.0 g/dL and an increased total bilirubin level of 2.1 mg/dL. Because hemobilia was highly suspected a contrast enhanced computed tomography (CT) of the abdomen was arranged emergently, revealing a round and hyperdense lesion abutting the T-tube choledochostomy (Figure The patient recovered well after the operation without fever episodes or jaundice. He was discharged on the 14y Figure . The cony Figure . He recoHemobilia, a rare but lethal disaster, was first described by Sandblom in 1948 as the situation of bleeding into the biliary tract following trauma . Blunt aAs for the etiological cause of pseudoaneurysm formation in our case, we propose that mechanical compression of the T-tube on the bile duct mucosa and adjacent proper hepatic artery might have caused erosion of the blood vessel, and induced pseudoaneurysm formation. There are evidences that might support our proposal. Firstly, anatomically speaking, the common bile duct runs along with the proper hepatic artery within the hepatoduodenal ligament. Secondly, the contrast-filled hyperdense pseudoaneurysm found at abdominal CT was just close to the T-tube. The angiographic features further disclosed that the lunar pseudoaneurysm was compressed by the T-tube and the contrast flew directly from the proper hepatic artery into the T-tube.The diagnosis of hemobilia can be confirmed by endoscopy examination or endoscopic retrograde cholangiopancreatography to directly observe bleeding from the ampulla of Vater . DopplerIn conclusion, pseudoaneurym associated hemobilia may occur after T-tube choledochostomy. This case also highlights the importance that hemobilia should be highly suspected in a patient presenting with jaundice, right upper quadrant abdominal pain and UGI bleeding after liver and biliary surgery. Once a diagnosis is established, angiographic intervention should be performed without delay because it is a life-threatening situation.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.UGI: upper gastrointestinal; CT: computed tomography; CBD: common bile duct.The authors declare that they have no competing interests.All authors have read and approved the final version of manuscript. LYT: surgical operation, drafting the manuscript; LH: helped to draft and edit the manuscript; CKY: carried out radiological intervention; WHS: involved in the clinical management of the patient; HMH: revised the manuscript critically and added substantial intellectual content; YSL: final review, supervision of scientific content of manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/10/81/prepub


The unusual event of surgical instrument retention in the abdominal cavity usually occurs after laparotomy.A 45-year-old African woman from Cameroon with no previous abdominal surgery presented with a three-day history of colicky abdominal pain. Abdominal X-ray showed an opaque, linear object in the lower abdomen. Exploratory laparotomy revealed a Hegar uterine dilator that was lost during a dilatation and curettage performed seven years prior to the present admission.The trans-uterine route should be included as a rare and unusual source of surgical instruments retained in the abdomen. Surgical instruments retained intra-abdominally usually occur after abdominal surgery and are straightforward to diagnose in conjunction with a history of previous laparotomy. Establishing the diagnosis pre-operatively of an abdominally retained surgical instrument in the absence of previous abdominal surgery will certainly be more challenging. Documenting and reporting all cases of retained surgical instruments not originating from previous abdominal exploration will help build a database and will educate physicians on how to avoid this dangerous medical error. From a literature search (Pubmed and Medline with no limitations until 2009) using search terms: abortion, Hegar uterine dilator, retained intra-abdominal surgical instruments, and bowel obstruction, no similar case reports were found. Hence, this case report documents the only known loss of a Hegar uterine dilator into the abdominal cavity during an abortion.3 with 73% neutrophils. Abdominal X-ray revealed a linear, opaque object in the lower abdomen, dilated small bowel loops, and air-fluid levels  gains momentum, such cases may become more frequent.The trans-uterine route should be included as a rare and unusual source of surgical instruments retained in the abdomen. This case can assist in the future development of a classification system for various routes of abdominally retained surgical instruments, as this case demonstrates a source other than previous laparotomy.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The author declares that they have no competing interests.COO analyzed and interpreted the patient data, wrote and approved the manuscript.


The presence of a large bulky pancreatic tumour in a young female should raise suspicions of the diagnosis of solid-pseduopapillary tumour of the pancreas.This rare tumour has the characteristics of a low-grade malignancy with indolent behaviour. Most patients present with vague non-specific abdominal pain resulting in delayed diagnosis. The light microscopic features show solid areas alternating with pseudopapillary formations. Metastases are frequently amenable to resection.Favourable prognosis with long-term survival has been shown even in patients with metastatic disease. Herein we present the case of a 21 year-old female patient of Afro-Caribbean extract who presented with gastric outlet obstruction from a large pancreatic tumour. Solid pseudopapillary tumors of the pancreas are rare and are often suspected in young females presenting with an abdominal mass. They are rarely found in children and commonly occur in women in the second to fourth decade of life. The pathogenesis is thought to result from cells of the endocrine pancreas though some investigators have postulated origin from the exocrine pancreas. These tumours have a long asymptomatic period and are usually detected when they have grown to a large size. Despite this presentation these tumours have low malignant potential. Metastases which are rarely seen occur mainly to the liver. It is therefore mandatory to establish a diagnosis and to attempt surgical excision even in large or metastasising tumours, since complete excision offers an excellent prognosis.A 21 year-old female of Afro-Caribbean extract presented with a 5-week history of intractable right- sided abdominal pain radiating to the back and associated with vomiting of bile-stained material. She gave a 1-week history of weight loss and jaundice. Her height was 165 cm and her weight 61 kg.On examination she was mildly icteric and anaemic. The abdomen was flat and a tender immobile epigastric mass 5 cm × 7 cm was identified. The haemoglobin was 9.1 gm/dl and the partial thromboplastin time was elevated at 48.1/30.1.The electrolytes, amylase and liver function tests were normal apart from elevation of the bilirubin with total bilirubin of 33 mmol/l and direct bilirubin of 12 mmol/l. Carcinoembryonic antigen (CEA) and CA 19-9 results were not available preoperatively.Abdominal ultrasound confirmed the presence of an abdominal mass in keeping with the physical findings. The CT abdomen identified an 8.1 × 7.7 × 7.5 cm mass in the head of the pancreas compressing the third part of the duodenum. Figure  Hard mesHer postoperative course was uneventful. The histology confirmed the diagnosis of solid pseudopapillary tumour of the pancreas. Adjuvant chemotherapy and radiotherapy were not offered. The patient remained well after a three-year follow-up period.Solid pseudopapillary tumours of the pancreas are rare. A total of 450 reports of solid pseudopapillary tumour of the pancreas have been reviewed in the literature since it was first described by Frantz in 1959. Most rep1-antitrypsin, and α1-antichymotrypsin and are negative for chromogranin, epithelial membrane antigen, and cytokeratin, insulin and glucagon.The majority of patients present with vague abdominal symptoms, resulting in a delay in presentation and diagnosis. The tumour exhibits typical features on light-microscopy. The cystic appearance on gross examination may present a diagnositic dilemma with cystic neoplasms of the pancreas. Immunophenotyping has been used to differentiate these tumours from other pancreatic neoplasms. Solid-pseudopapillary tumours test positive for vimentin, neuron-specific enolase, αThere are no clear histological features, which establish the clinical behavior of these neoplasms. The tumours exhibit low-grade malignant potential and metastasize infrequently. Local recurrence has been reported in less than 5% of cases.,7The identification of a large bulky pancreatic tumour in a child or woman should raise suspicions of solid pseudopapillary tumour of the pancreas. Because of the indolent nature of these tumours and the low malignant potential, aggressive attempts at complete surgical resection are warranted. Large tumours are usually resectable and size does not predict outcome. Surgical bypass may be the only feasible option in patients with large tumours where the risks of attempting resection or debulking may be associated with overwhelming morbidity.Cm: centimeters; kg: kilograms; gm/dl: grams/deciliter; mmol/l: millimoles/litre; CT: computed tomography.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All contributors contributed in the authorship, review, and compilation of this case report. All authors read and approved the final manuscript. The authors are abbreviated as follows: MECM, JMP, FKP and JP.


While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality. We present a case where CT was crucial diagnostically and helpful for pre-surgical planning in a patient presenting with an acute abdomen superimposed on complete congenital gastrointestinal malrotation.A 46-year-old previously healthy male with four days of primarily left-sided abdominal pain, low-grade fevers, nausea and anorexia presented to the Emergency Department. His medical history was significant for poorly controlled diabetes and dyslipidemia. His white blood count at that time was elevated. Initial abdominal plain films suggested small bowel obstruction. A CT scan of the abdomen and pelvis was performed with oral and IV contrast to exclude diverticulitis, revealing acute appendicitis superimposed on congenital intestinal malrotation. Following consultation with the surgical team for surgical planning, the patient went on to laparoscopic appendectomy and did well postoperatively.Atypical presentations of acute abdominal conditions superimposed on asymptomatic gastrointestinal malrotation can result in delays in delivery of definitive therapy and potentially increase morbidity and mortality if not diagnosed in a timely manner. Appropriate imaging can be helpful in hastening diagnosis and guiding intervention. Appendicitis is the most common surgical disease diagnosed in the emergency room setting. Gastrointestinal malrotation is, by comparison, relatively uncommon. Depending upon the location of the cecum and appendix, patients with acute appendicitis and malrotation may present atypically with left-sided abdominal pain. Left-sided abdominal pain most commonly raises the diagnostic question of possible diverticulitis, creating a diagnostic dilemma in these patients. Furthermore, a trend may be developing where diverticulitis, once a disease primarily of older adults, may be becoming more prevalent in younger adults  and may We present a case where the relatively common entity of appendicitis was in no way suspected prior to cross sectional imaging, which incidentally revealed gastrointestinal malrotation, significantly changing clinical management.®; 40 mg orally per day) and subcutaneous isophane/regular insulin (Insulin Novolin® 70/30) twice per day.A 46-year-old previously healthy male presented to Emergency Department with four days of primarily left-sided abdominal pain, low-grade fevers, nausea, and anorexia. His medical history was significant for poorly controlled diabetes and dyslipidemia. No history of abdominal surgery was reported. Two months prior to admission, the patient's serum hemoglobin A1C was markedly elevated at 10.7 and his serum lipid profile was quite abnormal . On admission, the patient's home medications included atorvastatin , hematocrit: 45.2%, serum glucose: 279, blood urea nitrogen (BUN): 31, and serum creatinine: 1.5. Serum electrolytes were as follows: sodium: 133, potassium: 4.2, chloride: 95, and CO2: 23 (anion gap 15). Urinalysis was positive for 2+ albumin, 1+glucose, 1+ ketones, 1+ bilirubin, and hyaline casts. Plain films of the abdomen were obtained in the Emergency Department. A spiral CT scan of the abdomen and pelvis with oral and IV contrast was subsequently performed to exclude colonic diverticulitis.The patient's physical exam at presentation was significant for left lower quadrant pain and voluntary guarding. The patient's white blood count at that time was 18.1 × 10Abdominal plain films demonstrated multiple dilated loops of small bowel with air/fluid levels in the right abdomen . Based on plain film findings of possible small bowel obstruction and absence of history of any abdominal surgery, an abdominal CT was performed, as discussed above.®).After extensive review of the CT data for presurgical planning, the patient was taken to the operating room for laparoscopic exploration and appendectomy, where the imaging findings were confirmed and the appendix was found to be perforated. No surgical intervention to address the malrotation, such as Ladd's procedure, was performed. Pathologic examination of the excised appendix verified the diagnosis of acute gangrenous appendicitis with perforation. The patient's post-operative course was uneventful. The patient was treated perioperatively with a 5 day regimen of intravenous cefoxitin  and as an outpatient with a 14 day course of oral levofloxacin  a priori unexpected location of the cecum and appendix, causing a diagnostic dilemma. In this case, a patient whose clinical presentation was initially most suggestive of diverticulitis was found to actually have acute appendicitis in the context of congenital bowel malrotation.Complete intestinal malrotation can result in common acute clinical entities such as appendicitis presenting atypically due to the CT was critical in this case in redirecting the primary clinical team, hastening the administration of definitive therapy, and for presurgical planning. The atypical presentation of acute appendicitis in patients with intestinal malrotation presents a diagnostic challenge. Appropriate imaging can be diagnostically decisive in identifying patients who present with such an atypical presentation of a common emergent clinical entity.The author(s) declare that they have no competing interests.FJW: Primary author; wrote and approved the final manuscript. MG: Provided clinical background and commentary. All authors read and approved the final manuscript.


Few cases of malignant rhabdoid tumour (MRT) of the liver are reported in literature andalways in paediatric patients. We report the first two cases of young adults submitted to hepatic resection for MRT of the liver. A major liver resection was performed in both cases. The histology showed round or fusiform, loosely cohesive cells. The cytoplasm containedabundant eosinophilic inclusions, which caused the nuclei to be located in eccentric locations, giving the characteristic rhabdoid appearance. The immunohistochemical study was performed, and characteristic lack of nuclear INI1 protein expression was found. In a case surgery was associated to chemoradiotherapy. One patient died at 48 months followup for tumour recurrence. The other is still alive at 25 months followup. MRTs are rare tumours of pediatric age with poor prognosis. Hypothetical less malignantbehaviour in the young adults could be supposed. Therefore an aggressive surgical and oncological treatment seems justified. Malignant rhabdoid tumours (MRTs) are highly aggressive tumours which usually presented in the central nervous system, in the kidneys and soft tissues of children. They were firstly described in 1978 as an aggressive variant of Wilms' tumour . Since tWe report the first two cases of young adults submitted to hepatic resection for MRT of the liver. The histological and immunohistochemical findings, the surgical treatment, and the clinical outcome are described. A 27-year-old male, in a good overall health, was admitted at the Emergency Unit for acute epigastric pain since 48 hours. The clinical examination of the abdomen found a mass at the palpation of the epigastric region. There was no weight loss, jaundice, diarrhoea, or vomiting. Trans-abdominal ultrasound revealed a large heterogeneous mass with intratumoral arterial vascularization, which occupied the left liver (15 × 7 cm) and the presence of peritoneal liquid in the Douglas space. The injection of contrast agent (Sonovue) showed a precocious hypervascularisation of the lesion whit hypoechogenic spots and late wash-out. No alterations of biological examinations and tumoral markers were revealed: alpha fetoprotein = 1.3 ng/mL , CA 19 − 9 = 15.2 U/mL . The CT-scan and the Magnetic Resonance Imaging (MRI) confirmed the ultrasound report and moreover showed a nodule of 1.5 cm on the segment VIII Figures . The sigA 15-year-old male, in a good overall health, presented acute epigastric pain and an upper abdominal palpable mass of recent appearances. The ultrasound and the CT-scan revealed a voluminous heterogeneous tumour of 15 cm in the left liver which compressed the surrounding structures (pancreas-stomach). Considering the high risk of hemorrhagic rupture, a surgical resection was decided. The surgical exploration showed a huge capsulated hepatic tumour compressing the portal vein without signs of infiltration of vascular structure. The tumour capsule presented signs of spontaneous rupture without active bleeding. A left hepatectomy (segments II-III-IV) was performed. There were no postoperative complication, and the patient was discharged at postoperative day 10. Because of capsule rupture and risk of tumour seeding an adjuvant chemotherapy consisting in 6 cycles of IVA  was proposed. At 30 months followup, the CT-scan showed two recurrence nodules involving the hepatic ligament and the peripancreatic region, measuring 6 and 7 cm, respectively. No others metastatic lesions were found. Chemotherapy consisting in 3 cycles of IVA followed by 3 cycles of adriamicine-cisplatine allowed an objective response, with mild reduction of the lesions to 4 and 5 cm, respectively. Complementary resection of the hepatic segment I and pancreaticoduodenectomy (PD) with extended lymphadenectomy was performed. The histology confirmed the recurrence of a rhabdoid tumour without lymphatic involvement. The patient underwent postoperative radiotherapy (40 Gy/20 fractions). At 43-month followup a new recurrence involving the remnant liver and the posterior bladder space was detected. A new chemotherapy with etoposide (3 cycles) was applied, followed by surgical exploration and resection of a voluminous retroperitoneal recurrence associated with right colon resection. The patient was discharged at postoperative day 15, but he died 1 month later due to a progressive cardiac failure. The surgical specimen measured, respectively, 17 × 15 × 8 cm/weigh 942 g (Case 1) and 15 × 14 × 14 cm/weigh 1400 g (Case 2). The macroscopic examination revealed a solid whitish tumour, with necrotic and hemorrhagic areas. The microscopic study showed a lobulated uniform aspect of fibrotic septa and glandular formations. The neoplastic cells were round or fusiform, loosely cohesive, and were seen within a fibromyxoid stroma. Ovular nucleus and prominent nucleolus were observed. The number of mitosis was moderate (maximum 8 at Gx400/10 fields). The cytoplasm contained abundant eosinophilic inclusions, which caused the nuclei to be located in eccentric locations, giving the characteristic rhabdoid appearance Figures . The cytThe immunohistochemical study was performed. The antivimentin antibody labelled the cytoplasm of almost neoplastic cells, including the cells with rhabdoid features. The anti-EMA  antibody diffusely marked the cellular cytoplasm with reinforcement of tumoral cells membranes. C-kit antibody significantly marked the cytoplasm of most neoplastic cells. Conversely the anti-PS-100, CK 22, CK 7, CK 19, CK 20, HMB45, desmin, myogenin, caldesmon, CD34, BCL2, synaptophysin, monoclonal NSE, and P53 antibodies did not remarkable labelled the neoplastic cells.The researches of specific genetic translocations for Ewing tumour, alveolar rhabdomyosarcoma, synovial-sarcoma, and myxoid chondrosarcoma were negatives. Finally the immunohistochemistry demonstrated lack of nuclear INI1 protein expression.  MRT was first identified in the kidney of infants and children and was described in 1978 as rhabdomyosarcomatoid variant of Wilms' tumor . HoweverWith the same morphologic and immunohistochemical features, identical tumors have been reported in a wide variety of sites including the nervous system, eye, tongue, nasopharynx, neck, mediastinum, thymus, heart, uterus, urinary bladder, vulva, skin, soft tissue, paravertebral region, and gastrointestinal tract , 9. ExtrIn summary, primary malignant rhabdoid tumours of various organs have been described in literature. Only rare cases are seen in the gastrointestinal tract, in particular, the liver. These poorly differentiated neoplasms may pose a great deal of difficulty in the diagnosis because there is no glandular, squamous, or any other differentiation. In addition, it is almost impossible to make the distinction whether the tumour is of primary origin or represents a metastasis from rhabdoid tumour of a different site. In the two cases no other extrahepatic lesions were found at pre-operative imaging studies and surgical exploration. Liver rhabdoid tumour is a rare histological finding especially in young adults. In a review article published in 2004, Yuri et al. , the outAs concern chemoradiotherapy, no consistently effective regimen has yet been established. Ifosfamide, vincristine, cyclophosfamide, etoposide, epirubicin and actinomycin D based chemotherapies are the treatments of choice. Banzai et al.  reportedThe aggressive and incurable nature of rhabdoid tumors corroborates the need to develop a targeted and effective therapy for these tumors. Rhabdoid tumors and cells are exquisitely dependent on cyclin D1 for genesis and survival, suggesting that targeting the cyclin/cyclin-dependent kinase (cdk) axis may be an effective therapeutic strategy for these tumors. Currently, there are several studies regarding the use of a pan-cdk inhibitor, flavopiridol, that both inhibits cdk activity and transcriptionally down-modulates cyclin D1 which may effectively inhibit rhabdoid tumor growth. Flavopiridol is potentially a novel chemiotherapeutic agent for rhabdoid tumors .In conclusion MRTs are rare liver tumours. Histological diagnosis is not always easily achieved, but lack of expression on INI1 protein at immunohistochemistry could be helpful. Usually liver rhabdoid tumours developed in pediatric patients and in most of the cases the prognosis is very poor. Presentation in young adults is exceptional, and they probably have a better biological behaviour. As concern chemoradiotherapy no consistently effective regimen has yet been established. Aggressive surgical conduct seems justified also in case of recurrence disease.


Snapping hip, or coxa saltans, is defined as a clinical condition where a usually painful, audible snap occurs during hip flexion and extension. Its causes can be divided into external, internal or intra-articular origin. Accurate diagnosis is a prerequisite to successful treatment. We report a rare cause of snapping hip which is different from any previously reported cases.A 23-year-old man presented to us with right hip pain of more than 10 years duration. Atrophy of the right gluteus maximus with snapping and tenderness were also noted. The imaging study revealed a focal intramuscular lesion in the lateral portion of the right gluteus maximus muscle. Surgery was performed and pathological examination concluded this mass to be a venous hemangioma.Intramuscular hemangioma, though rare, should be considered in the differential diagnosis of a snapping hip even though muscle fibrosis is most frequently encountered. A snapping hip, or coxa saltans, is characterized by a usually painful snapping phenomenon during hip flexion and extension. The causes of a snapping hip can be grouped into external, internal or intra-articular origin . Since eWe report a relatively rare cause of a snapping hip. The etiology of the snapping hip of this 23-year-old man had been misinterpreted as muscle fibrosis, the most common cause for this symptom, for more than 10 years. Interestingly, the preoperative assessment and pathological findings were subsequently demonstrated to be different from any previously reported causes. The cause turned out to be an intramuscular tumor located close to the gluteus maximus insertion around the greater trochanter.A 23-year-old Taiwanese man, who had suffered from right hip pain for more than 10 years, requested an orthopedic consultation. He stated that a computed tomography (CT) examination 10 years ago for hip pain disclosed no abnormal findings. However, the hip pain persisted and radiated to the buttock intermittently, especially when he adducted and flexed his right hip joint. The pain could be temporarily relieved by either abduction or the use of painkiller medication.On physical examination, atrophy of the right gluteus maximus with snapping and tenderness of the right hip was noted. A tight tensor fascia lata without an obvious palpable mass was suggested. Under the suspicion that this was not a case of common tensor fascia lata fibrosis, magnetic resonance imaging (MRI) was arranged and surprisingly revealed a focal intramuscular lesion in the lateral portion of the right gluteus maximus muscle, approximately 3.5 × 1.5 × 4.4 cm in size, which was hypointense in T1W and hyperintense in T2W under contrast enhancement (Figures The patient agreed to surgical management for both the relief of the symptoms and to determine the pathology of the lesion. The gluteus maximus muscle was exposed during the operation and a hypervascular soft-tissue mass was noted Figure . We perfThe most common type of snapping hip is the external type caused by the iliotibial band sliding over the greater trochanter ,7. The iet al. reported a patient with external snapping hip caused by an osteochondroma of the proximal femur [A tumor in the gluteus maximus muscle might mechanically irritate the smooth movement between the iliotibial band and the greater trochanter, or cause a tight tensor fascia lata, mimicking a snapping hip. However, very few cases have been reported concerning the relationship between a local tumor, not of intramuscular origin, and a snapping hip, except in 2005 when Sanshiro al femur . The symIn our patient, the hemangioma grew in the lateral part of the gluteus maximus muscle insertion superficial to the greater trochanter and disturbed the smooth movement of the iliotibial band over the greater trochanter. Such an etiology has not been reported before in the literature.Skeletal muscle hemangioma is probably the most common form of hemangioma of deep soft tissue, and might be located in the retroperitoneum, mesentery or muscles of the lower extremities. Nevertheless, it is rare when considering the spectrum of benign vascular neoplasms . It accoAccording to histological subtyping, haemangiomas can be divided into capillary, cavernous and venous types. A venous hemangioma is rare and is characteristically present during adult life . Pain isAn intramuscular hemangioma, though rare, should be considered in the differential diagnosis of a snapping hip even though muscle fibrosis is the most frequent cause.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.CLL collected the patient data, reviewed the literature and was a major contributor in writing the manuscript. MTH advised about the writing of the article, interpreted the clinical significance of the aetiology and participated in the surgical intervention. CJL was the visiting staff member for the patient and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.


Metastatic involement of penis is an exceptionally rare condition. 77% of the metastases are originated from the pelvic region; prostate and bladder are the most frequent primary locations. Retrograde venous route, retrograde lymphatic route, arterial spread, direct extension, implantation and secondary to instrumentation are the mechanisms of metastasis. Approximately two thirds of all penile metastasis are detected at a mean time of 18 months after the detection of the primary tumor and the remaining one third is presented at the same time with primary tumor. Diagnosis is usually made by biopsy and also non invasive methods as MRI or colour-coded duplex ultrasonography. Treatment options in these patients are local excision, partial or complete penectomy, external beam radiation therapy and chemotheraphy. Despite these alternatives prognosis is usually poor.We present a case of urethelial carcinoma of the bladder and coincidental prostate adenocarcinoma with penile metastasis which is presented with priapism 6 months after radical cystectomy as the first systemic manifestation. We performed biopsy initially for staging and the patient underwent MRI showing the extension of the disease. The patient underwent radiotherapy of 56 gy and priapism partially resolved after the treatment. Chemotheraphy was also planned but the patient died 3 months following radiotheraphy. Metastatic involement of penis is an exceptionally rare condition. The first penile metastasis case was reported by Eberth in 1870 . We presA 74-year-old Turkish Caucasian male patient, with high grade urethelial carcinoma of the bladder with evidence of lamina propria invasion was referred in January 2007. He had the diagnosis 9 months before that time, and after the operation 6 cycles of cisplatin and gemcitabine combination was given to patient by a medical oncology clinic from an outside center. He had smoked for 20 years and had intermittant painless hematuria for 2 months before the initial diagnosis. Digital rectal examination was unremarkable and the physical examination revealed normal. Laboratory data revealed hematocrit 40.2%, hemoglobin 12.8 ng/dl Urea: 54 mg/dl, creatinin: 1.21%/mg and PSA: 3.8 ng/dl. On cystoscopy, a broad based papillary tumor about 3 cm at the dome was diagnosed. Histological examination of the biopsy specimen revealed high-grade urethelial carcinoma of the bladder with invasion of the muscularis propria. He underwent radical cystoprostatectomy and bilateral pelvic node disection with an ileal conduit diversion in February 2007. Pathological examinaton revealed high-grade, infiltrative urethelial carcinoma of the bladder (pT3a/WHO 2004) surgical margins were negative and carcinoma insitu was not detected. Incidentally, prostatic adenocarcinoma, Gleason's score of 8 (4 + 4) with invasion at the apical surgical margin and left seminal vesicle was detected. External iliac, obturator lymph nodes and distal end biopsies of both ureters were negative for neoplasia. Six months after cystectomy, patient presented with priapism, pain, and urethral discharge. On physical examination penis was erect and swollen, nodules were palpated at glans, left and right side of the penile shaft. On digital rectal examination there was no suspicion for tumor involvement. PSA level of the patient was 0.002 ng/dl. An excisional biopsy from glans and tru-cut biopsies from cavernosal bodies were performed. Pathological examination of the excisional biopsy revealed, infiltration of carcinoma at subephitelial area with vascular invasion (Figure It is still unknown, why does penile metastasis is infrequent despite the fact that penis has got rich vascularazition and intensive venous communication with neighbouring organs. Up to date over 370 cases are reported . RetrogrGy: gray; MRI: magnetic resonance imaging; PSA: prostate specific antigen.Written informed consent was obtained from the patient's son for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.NCS was the organizer of the case report, surgeon responsible for the diagnosis. BC was the organizer and resident responsible for the follow up of the case. SA was the surgeon responsible for the radical cystectomy and researcher of the literature. SG was the surgeon responsible for the radical cystectomy and researcher of the literature. AD was the authority and director of the case report.


Malignant mesothelioma is one of the rare tumors of pleura. One such case in a 57-year-old male, who presented with hemorrhagic pleural effusion and had no history of asbestos exposure, is reported here. The rarity, unusual presentation, and implications are discussed. Malignant pleural mesothelioma (MPM) is the most common neoplasm of pleura.1Mr. P, a 57-year-old male, presented with complaints of dyspnea on exertion and left-sided chest pain for 15 days. History revealed smoking index to be 250. He was a known diabetic under regular treatment. There was no other significant history.Examination revealed thin built, anemic, dyspneic individual with signs of pleural effusion on the left side. On investigation, chest X-ray revealed left-sided pleural effusion. There was no other pleural or parenchymal abnormality. Diabetes was under adequate control. Other hematological and biochemical parameters were within normal limits.Pleural aspiration revealed hemorrhagic fluid which was exudative. Fluid examination did not show acid fast bacilli or any malignant or abnormal cells. Hence, CT scan of thorax was perfomed that suggested the lesions to be probably infective, with no evidence of malignancy . EmpiricMPM is a rare tumor even in Western world and still rarer in India. The incidence in men ranges from 7–13 per million per year. In population unexposed to asbestos it is still rarer, with reported incidence of 1–2 per million per year.56MPM usually occurs in males with a male to female ratio of 2.6:1. It is usually related to asbestos exposure, though rarely it can occur in patients not exposed to asbestos. In such cases, the postulated correlation is operation of other carcinogens, genetic factors, and viral infections.7Patients usually present with pleural effusions. Radiographic investigations reveal pleural effusion (exudative/hemorrhagic), pleural nodular shadows , or involvement of lungs, ribs, spine, etc.Histologically, MPM are of three types: (a) sarcomatoid type, appearing as a spindle cell carcinoma resembling fibrosarcoma, (b) epithelial type, consisting of cuboidal, columnar, or flattened cells forming a tubular and papillary structure resembling adenocarcinoma, and (c) biphasic type, containing both epithelial and sarcomatoid (mixed) patterns. The histological picture in this case was suggestive of epithelial type.A search of literature for reported cases from India confirmed the rarity. In a retrospective study,The rarity of the occurrence, the absence of exposure to asbestos, and the unusual presentation prompted us to report this case.


Early diagnosis of diaphragmatic rupture after traumas may be difficult, and delayed diagnosis may result in increased morbidity and mortality. This paper describes the case of a 32-year-old man who experienced a traffic accident and had diagnosis of traumatic diaphragmatic hernia nearly four months later. The patient was referred to our emergency room suffering from ileus symptoms. Physical examination demonstrated an apparent abdominal distention, tenderness at the upper abdominal quadrants, rebound, and defense. Thoraco-abdominal X-rays and computerized tomography imaging demonstrated intestinal segments with air-fluid levels in thorax. Laparotomy was performed after a preoperative diagnosis of a strangulated-diaphragmatic hernia. At abdominal exploration, it was found that transverse colon and omentum entered into thorax through diaphragmatic defect located at the left diaphragm. Herniating colon segment was complicated with ischemic necrosis and perforation. In conclusion, colon necrosis and perforation may develop when early diagnosis of diaphragmatic ruptures are missed. Diaphragmatic injury was first reported by Sennertus in 1541 and was repaired successfully by Riolfi for the first time in 1886  and 4.5-Herein a 34-year-old Caucasian Turkish male patient who experienced a traffic accident and had the diagnosis of TDH nearly four months later is presented. TDH was secondary to a blunt trauma that resulted from a traffic accident outside the vehicle. After the first trauma, the patient complained of several symptoms such as constipation, shortness of breath which especially increased with effort and pain at upper abdominal quadrants. Nevertheless, those symptoms were increased in severity for the last ten days. The patient was referred to our emergency room suffering from ileus symptoms such as inability to pass gas or stool, abdominal distension, nausea-vomiting and fever. Physical examination demonstrated an apparent abdominal distention, tenderness at the upper abdominal quadrants, rebound and defense. Thoraco-abdominal X-rays  and compMechanism of an injury due to a blunt trauma can be explained by lateral impact that leads to distortion of chest wall, and direct frontal impact resulting in increased intra-abdominal pressure; thus both causing a diaphragmatic injury and visceral herniation. Although blunt trauma may cause an injury at any of the part of the diaphragm, most injuries occur in the postero-lateral aspect of the left side of the diaphragm. Traumatic diaphragmatic injuries may be due to blunt 68-75%) and penetrating (25-32%) traumas. Diaphragmatic injuries mostly occur in young men and left-sided hemidiaphragmatic injuries are more common (56-90%) [% and penIn case of TDH, abdominal organs may herniate into the thorax due to pressure difference between the peritoneal space and thorax. As the diameter of the diagraphmatic injury increases in time, herniating of the abdominal organs and subsequent clinical symptoms ensue. Herniating organs into thorax make a pressure on the lungs and lead to mediastinal shift. Therefore, some patients may be referred to hospital complaining of cardiac and respiratory symptoms. Herniating organs may be related with a number of additional symptoms and signs such as gastrointestinal distress and ileus . DyspneaThere is a common consensus that radiological studies may be helpful to diagnose traumatic diaphragmatic hernias. Nevertheless, there are some restrictions in the diagnostic modalities to diagnose traumatic diaphragmatic injuries. It may be difficult to diagnose a traumatic injury both in early and late cases and therefore it is very important to suspect a traumatic injury condition. In a study, Shah et al., showed that the disorder was diagnosed preoperatively in 43.5% of 980 cases, but the diagnosis of 41.3% of the patients was performed during autopsy or surgical exploration, and in the remaining 14.6% of the patients, diagnosis was delayed . Chest XA surgical intervention can be carried out for a TDH through the abdominal or thoracic route. Abdominal organs may have changed their locations toward the thorax. When evaluating an abdominal trauma and organs located in the abdomen, an abdominal approach should be considered. Delayed TDH may require a thoracic approach to ease the release of adhesions in the thorax. The thoracic approach is preferable in patients with a thorax trauma, a large defect in the diaphragm and accompanying emphysema. If necessary, an abdominal exploration can be conducted by a thoraco-abdominal incision .However, abdominal approach can be more convenient in case of abdominal organ injury. TDH must be restored by non-absorbable sutures or synthetic grafting. In our case, there was a delay of 4 months. Preoperative physical examination, thoracoabdominal X-ray and computerized tomography showed a herniating colon into the thorax. Consequently, colon resection was performed by abdominal approach and restored successfully with nonabsorbable sutures. However, there was no need for synthetic grafting for the repair of hernia. The present case was complicated with wound infection. The absence of complications related with the thorax such as atelectasis was attributed to the omental wrapping of the colonic perforation site.In conclusion, a history of trauma must be investigated to diagnose the patients with a delayed TDH condition due to a blunt trauma. An unnoticed TDH must be kept in mind. A careful examination of the thorax X-ray and computerized tomography imaging may be helpful. Colon necrosis and perforation may ensue when the early diagnosis is missed.


This report describes the radiological and histological findings of a small cell osteosarcoma of a toe phalanx in a 38 year old man. This man presented with pain, swelling and redness of the left third toe. Medical history revealed an osteomyelitis of this toe eight years prior. Based on clinical findings and medical history the lesion was diagnosed as an osteomyelitis. However, peroperatively the lesion had a malignant aspect. Histological examination revealed a small cell osteosarcoma of the proximal phalanx.Osteosarcoma of the foot and especially of the tubular bones is rare. Moreover small cell osteosarcoma is a rare subtype of osteosarcoma. This case demonstrates that medical history and clinical examination can be misleading. In patients with apparent bone destruction, a malignancy must always be excluded prior to treatment. It emphasises the care that should be taken in the process of formulating a diagnosis. Osteosarcoma (OS) is the most common primary malignant bone tumor in children and adolescents with a peak incidence at age 15-19 years old. Typically, it originates from the metaphysis of long bones and has a high tendency to systemic spread [Osteosarcoma of short tubular bones is a rarity -5. An osOsteosarcoma in the foot represents approximately 0,5% of all osteosarcomas ,3. As opSmall cell osteosarcoma, first described in 1979 by Sim et al , classifTo the best of our knowledge, this is the first case of small cell osteosarcoma originating from a phalanx presented in English-language literature.In the year 2000, a 30 year old, otherwise healthy male presented with pain, swelling and redness in his left third toe. Radiological findings showed a pathological fracture of the proximal phalanx of the third toe on the basis of an intra-osseous lesion with a spotted and sclerotic aspect. An MRI was made showing a clear abnormality of the proximal phalanx of the third toe with oedema of the bone marrow and minimal reaction in the adjacent soft tissue. There was no extra-cortical expansion. Osteomyelitis or Ewing's sarcoma could not be excluded. Fig. In January 2001 a biopsy was performed. Histopathology showed cortical and cavernous bone tissue with reactive changes and damaged cells of which identification was not possible. The bone abnormalities were considered to be reactive in nature and the diagnosis was set as osteomyelitis.The patient's complaints diminished spontaneously. No antibiotic treatment was prescribed. In April 2001, a control radiograph showed a normal structure of the third proximal phalanx of the left foot. The patient was discharged from follow-up in the outpatient clinic.At the time of the second presentation, in 2008 with the patient being 38 y, the same symptoms occurred. They were present since six weeks. Physical examination showed clear swelling and tenderness of the left third toe. There was no ulceration.The conventional anteroposterior radiograph Fig.  of the lThe total-body bone scintigraphy showed high uptake of TC-99M in the left third toe and was suggestive of osteomyelitis. There were no other hotspots.The clinical diagnosis was set at osteomyelitis and the patient was surgically treated as such. In august 2008 the proximal phalanx of the left third toe was surgically removed. Macroscopically there was a large mass in the surrounding soft tissue with calcifications. The findings were highly suggestive for a malignancy. Due do the initial diagnosis of osteomyelitis the surgical margins were intralesional.Histological examination followed.  Microscopically there are large fields of atypical small blue round cells. The cells are highly undifferentiated and are very uniform in appearance. The nuclei are dark and round to oval, there is little cytoplasm. There is osteoid formation by the tumor cells. Fig.  The pathMetastatic disease was not found on a CT-scan of the thorax and abdomen.  An additional MRI of the left foot was made in September 2008. This showed the initial post-operative situation. Fig From November 2008 the patient was treated according to the EURAMOS-1 trial . In FebrIn retrospect, the initial abnormalities in 2001 are verified as infectious by the pathologist.Small cell osteosarcoma is rare and relatively little English-language literature is available on this subject. Most publications comprise case reports.The clinical and radiological features resemble those of the conventional osteosarcoma. The most common clinical features of small cell osteosarcoma are pain and swelling . Often, On radiographs small cell OS shows lesions with either lytic or sclerotic features, or a combination of the two ,10,14,15Small cell OS is a distinct subtype of conventional osteosarcoma with its own histological entity. Typically small cell OS shows a uniform population of small, round cells with little cytoplasm and indistinct cell borders. The nuclei are round, occasionally oval shaped. Osteoid production is always present ,12,13,15Small cell osteosarcoma is considered an aggressive subtype of OS with a poor prognosis ,10,12,17The Rizolli institute has described clinical, radiological and histological characteristics of small cell OS in a group of patients . RadioloThe pattern of metastasis is concordant to that of conventional OS. Metastases are most commonly found in the lungs , althougThe treatment of small cell OS is similar to the conventional OS treatment ,10. It cApart from the rarity of small cell OS, the patient in this case suffered from an OS on a rare skeletal location. In the literature available on osteosarcoma of the tubular bones (mostly of the hand), it is noted that osteosarcomas of the digits more commonly low-grade . Most osSince OS of the phanlanges is such a rarity, late or misdiagnosis is common, as was the case in this patient.It is extraordinary that this patient developed an osteosarcoma at the exact same location where he previously suffered an osteomyelitis. This poses the question whether there is a connection between the two ailments.According to literature, it is unclear whether osteomyelitis is an etiological factor in the development of osteosarcoma. Although malignancies arising from a draining infection are relatively common, malignant degeneration of chronic, draining osteomyelitis into a sarcoma is seldom . Most maOsteosarcoma of the phalanges of the foot is extremely rare. Often there is a delay in diagnosis because of patient delay and mildness of symptoms, or because of misdiagnosis at presentation. It affects adults rather than adolescents. In adults with a mixed lytic and sclerotic lesion on the X-ray, an osteosarcoma in the foot should be considered in the differential diagnosis.This report was written to accentuate the risk of misdiagnosis in the case of a rare disease in a patient with only mild symptoms. A thorough pre-operative work up is always necessary. In the case of a destructive bone lesion, always rule out a malignancy prior to surgical treatment.The authors declare that they have no competing interests.JPDB: designed manuscript, collected patient information and performed literature search. HCAG: advised on design and corrected manuscript. JB: analysed histological samples, approved manuscript. RSA: supervised project, provided patient information and corrected manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and the accompanying images and coupes. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Open drains are frequently placed in the abdominal cavity to prevent the collection of fluid or blood following major surgery.We describe a case of perforation of the large bowel caused by the drain tube placed in a 74-year-old patient who had undergone radical cystectomy for invasive bladder cancer. Perforation of the large bowel secondary to pressure necrosis caused by open drainage tubes is an extremely rare complication following major intra-abdominal surgery. Currently only twelve cases been reported in the literature, all in general surgery operations -7. We deA 74-year-old patient with a past medical history of diabetes, cerebral vascular disease and a moderate degree of cardiac insufficiency underwent radical cystectomy for an extensive T2G3N0M0 bladder tumor. Prior to surgery there was no evidence of preexisting bowel disease, while the patient had never been operated intraabdominally or undergone a preoperative colonoscopy. A left crossed renal ectopia was found, during the urologic evaluation which included an excretory urogram (IVU) and an abdominal computed tomography scan.The patient was classified as ASA score III and his operation was considered of increased surgical difficulty because of the presence of the fused left renal ectopia abutting the bladder and iliac vessels. As a consequence a fully informed consent was signed preoperatively. The patient underwent an uneventful 4-hour radical cystectomy and an ileal conduit with bilateral end to side uretero-enteric anastomoses was created. The stoma was fashioned at the pre-selected site at the right lower abdominal quadrant.th postoperative day, bowel content appeared in the drain. A contrast CT scan of the abdomen and pelvis revealed a patent and intact small bowel anastomosis but confirmed a sigmoid colon perforation. Recall of the surgical procedure and review of the CT films (Fig. th postoperative day due to increased bowel content effluence and septicemia. The sigmoid colon perforation was confirmed, by finding a hole of about 5 cm in length and 1 cm in width and a Hartman's colectomy was performed. Although the drain had been withdrawn prior to the exploratory laparotomy, the shape of the bowel injury was consistent with an imprint of the drain, as shown in the CT scan preoperatively.(Fig th postoperative day and due to ongoing and refractory sepsis the patient deceased. Histopathology of the resected left colon revealed ischaemic bowel disease with extensive bowel mucosa necrosis and atherosclerotic plaques and thrombotic lesions of the bowel wall vessels.The peritoneal cavity was drained by an open-ended latex flexible tube of 8 mm in internal diameter which entered from the left lower quadrant and was placed at the pelvis, at a length of about 15 cm. The tube was draining to gravity, without any suction. The drain had also two side holes at its last 5 cm length, for better drainage. Patients' recovery was slow, as bowel mobilization was delayed but without clinical or radiographical confirmed ileus. As a consequence the drain remained in the aforementioned position, although its output did not exceed 200 ml for five days and there was no evidence of urine leakage. On the 6Bowel perforation caused by drainage tubes following abdominal surgery is a rare complication, with only twelve cases thus far reported in literature -7. All cASA: American Society of Anesthesiologists; CT: Computed Tomography.Written informed consent was obtained from the patient's sons for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.EPC, AS, EM, IM and GA conceived the study and participated in its design, coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


Esophagogastroduodenoscopy, until the second part of duodenum, was normal. Ultrasound and computed tomography demonstrated a solid mass in the distal duodenum. A repeat endoscopy confirmed an ulcerative, intraluminar mass in the third and fourth part of the duodenum. Segmental resection of the third and fourth portion of the duodenum was performed. Histology revealed an adenocarcinoma. On the 4 Although the small intestine constitutes over 75% of the length and 90% of the mucosal surface of the gastrointestinal tract, small intestine cancer is rare and accounts for only 1% of gastrointestinal malignancies . AdenocaDuodenal adenocarcinomas represent approximately 0.3% of all malignant gastrointestinal tumours and the vast majority of them is found in the second portion of the duodenum ,2. AdenoA 65-year-old Greek woman  with a free past and family history, presented with a two month history of intermittent abdominal pain, weight loss, and fatigue. The patient had two normal labours, while she did not smoke, consume alcohol or take any medication. Clinical examination was normal. Blood tests, including tumour markers such as carcinoembryonic antigen (CEA), a-fetoprotein (AFP), carbohydrate antigen 19-9 (CA 19-9), and carbohydrate antigen 125 (CA 125), were within normal limits apart from microcytic anemia (hemoglobin: 8.0 gr/dl). Esophagogastroduodenoscopy, until the second portion of the duodenum, was normal. Abdominal ultrasound (US) finding of a hypoechoic mass with irregular margins in the distal duodenum led to a contrast-enhanced abdominal computed tomography (CT) scan that revealed a solid mass (6 × 5 cm) in the third and fourth part of the duodenum   Figure . The speth postoperative day, the patient developed severe acute pancreatitis and was admitted to the Intensive Care Unit. She developed multiple organ failure and died on the 30th postoperative day.On the 4Few cases of adenocarcinoma of the third and/or fourth portion of the duodenum have been reported -11. CausAdenocarcinoma of the third or fourth part of the duodenum presents a diagnostic challenge. Symptoms may be absent until the tumour has progressed leading to a delay, of several months, in presentation ,7,8. TheDiagnosis is usually made by upper gastrointestinal contrast study and endoscopy ,5,7-11. Abdominal US is helpful for diagnosis and evaluation of vascular involvement ,8. LesioThe treatment of choice is radical surgical resection ,4-11. ThLittle is known about the use of radiotherapy and chemotherapy, but most physicians utilise therapeutic strategies modeled on the management of large bowel cancer . CunningAdenocarcinoma of the third and fourth part of the duodenum is very rare. Patients typically present with a long history of variable, vague symptoms and, many, with advanced disease. A higher degree of suspicion and a more aggressive, persistent investigation should lead to earlier treatment, higher curative resectability rate, and, therefore, better long-term results. The treatment of choice is radical surgical resection. The optimal surgical procedure, though, remains controversial. Multi-institutional prospective studies comparing pancreaticoduodenectomy with segmental resection or wide local excision as well as trials of chemotherapy and radiation therapy are needed to identify their impact on prognosis and suggest appropriate treatment recommendations.The authors declare that they have no competing interests.HM contributed to manuscript conception, research, acquisition of data, drafting and writing of the manuscript. DT contributed to organising and drafting of the manuscript, and critically revised the manuscript. KGT contributed to organising and drafting of the manuscript, and critically revised the manuscript. GG carried out the histopathologic evaluation and contributed to writing of the manuscript. SK contributed to organising, drafting and critical review of the manuscript. IB carried out the operation and contributed to acquisition of consent and critical review of the manuscript.All authors read and approved the final manuscript.Written, informed consent was obtained from the daughter of the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


The spontaneous resolution of pseudopancreatic cyst due to internal fistulization into the duodenum in a 4-year-old male child is described here. This is rare and the child presented initially with features of duodenal obstruction. Upper gastrointestinal endoscopy and computed tomography scan confirmed the diagnosis and the unusual mode of resolution of this entity. Pseudocyst of pancreas is rare in children.2 A revieA 4-year-old boy presented with 3 days history suggestive of duodenal obstruction. On clinical examination, the patient appeared irritable with no evidence of fever or hemodynamic instability. The abdominal examination was unremarkable except mild discomfort in epigastrium on palpation. Plain abdominal radiograph was suggestive of high small bowel obstruction. Upper gastrointestinal contrast study showed obstruction in the second and third part of the duodenum. The contrast did not pass beyond third part of the duodenum. He was managed conservatively with nasogastric (NG) aspiration, intravenous fluids, and H2 blockers. He had large amount of greenish aspirate from the NG tube every day. His routine hematologic investigations and biochemistry were normal except high serum amylase level (307 U/L). An abdominal ultrasound showed a cystic mass (8 × 9 cm) in the epigastrium in relation to the head of pancreas. Computed tomography scan of abdomen showed similar finding and a diagnosis of pseudocyst at the head region of pancreas was made. Upper gastrointestinal endoscopy showed narrowing of duodenal lumen beyond the second part due to extraluminal compression of C-loop of duodenum . There wAlthough there was no definite evidence of abdominal trauma in the present case, trauma has been reported as the most common cause of pseudocyst of pancreas in children.–4 FeaturThe natural history of pseudocyst of pancreas in children has not been well understood.4 AlthougThus we conclude that pseudocyst of pancreas remains a rare entity in the pediatric age group, mostly associated with delayed diagnosis owing to its obscure etiology and nonspecific clinical presentation. Although spontaneous internal fistulization is extremely uncommon in the pediatric age group, it should be confirmed with endoscopy in pediatric patients undergoing prompt resolution of symptoms, especially when there is a large pseudocyst of pancreas.


A case of giant meconium pseudocyst secondary to ileum volvulus perforation is presented. Conventional radiographic features of meconium peritonitis with secondary meconium pseudocyst formation are well described. Our case is unusual in comparison to other cases reported in the literature and needs to be reported because the meconium pseudocyst presented without the typical ultrasound features  and was initially identified as an abdominal mass.We describe the case of a 29-year-old Caucasian woman in her third trimester of pregnancy, in which an abdominal mass was detected in the fetus. The newborn was diagnosed in the early neonatal period with meconium pseudocyst secondary to ileum volvulus perforation.The prenatal appearance of a meconium pseudocyst can be complemented by other signs of bowel obstruction (if present) such as polyhydramnios and fetal bowel dilatation. This is an original case report of interest to all clinicians in the perinatology and fetal ultrasound field. We consider that the utility of this case is the recognition that a meconium pseudocyst might appear without the typical ultrasound features and should be considered as a differential diagnosis when an echogenic intra-abdominal cyst is seen. Intra-uterine intestinal perforation causes a sterile inflammatory reaction of the peritoneum known as meconium peritonitis.The ultrasound diagnosis of meconium peritonitis should be considered in the presence of a fetal intra-abdominal hyper-echoic mass, particularly if associated with ascites and polyhydramnios. Meconium cysts usually contain characteristic punctate echogenic calcifications as well.With technical advances in imaging and increasing use of high-resolution ultrasonic equipment, a significant number can now be diagnosed prenatally. Magnetic resonance imaging may also be a valuable diagnostic tool.Meconium pseudocyst secondary to ileum volvulus perforation is an uncommon cause of fetal abdominal mass. We report an unusual case of meconium pseudocyst presenting without the typical features identified on ultrasound examination.A 29-year-old Caucasian woman with a 32.3 week, twin bicorial biamniotic pregnancy was admitted to the Emergency Service with threat of preterm labor. Tocolysis with atosiban and fetal lung maturation pattern were provided.Social and medical history were remarkable for gestational diabetes and a previous evaluation for primary sterility through laparoscopy and hysteroscopy, but were otherwise non-contributory.The first day of hospitalization 32.3 weeks), third trimester fetal ultrasound was performed. An abdominal mass occupying the entire left hemiabdomen with mixed echogenicity was identified in the first fetus  Figures  and 2. N.3 weeks,Fetal magnetic resonance imaging (performed at 32.4 weeks) identified a 72 × 58 mm, heterogeneous, mesenteric mass without necrosis causing significant distortion of the small intestine to the left. There were no pathologic findings in the rest of abdominal structures . Birth weights were 1980 g (fetus 1) and 2060 g (fetus 2).Laparotomy and bowel resection were performed within the first day following delivery. During surgery a 10 cm, volvulated, necrotic portion of small intestine was identified, at 10 cm from ileocecal valve. Small bowel volvulus resection, termino-terminal anastomosis, and appendectomy were performed.Pathological anatomy reports revealed distal ileum vascular congestion, intestinal wall bleeding and areas of acute inflammation.The final diagnosis was a perforated ileum volvulus and secondary meconium pseudocyst.Bowel obstruction was suspected at three days following the initial surgical intervention. A second laparotomy identified a segment of obstructed bowel. This was resected and a termino-terminal re-anastomosis was performed. Sweat chloride test for cystic fibrosis was negative.Due to the newborn's torpid post-operative course and lack of gastrointestinal tolerance, an exploratory laparotomy was performed 51 days after birth. Intra-operatively, a stenosis of the re-anastomosis was observed. Resection of a 5 cm section of bowel including ileocecal valve, as well as ileostomy and colostomy were performed.The newborn remained hospitalized receiving total parenteral nutrition and with secretory diarrhea due to short bowel syndrome, and died during the seventh month of life.The differential diagnosis of a sonographically visualized intra-abdominal cyst in a fetus is extensive, and includes intestinal duplications cyst, mesenteric cysts, choledochal cyst, meconium pseudocyst, congenital cyst of the pancreas, renal cyst, obstructive uropathy, urachal cyst, ovarian cyst, ureterocele and tumorous lesions such as cystic sacroccocygeal teraromas.Fetal tumors comprise 0.5% to 2% of all childhood neoplasms. Extra-cranial teratomas, neuroblastomas, soft-tissue and intra-cranial tumors are the most common . The remaining 15% are made up of renal tumors, liver tumors, retinoblastoma and other less common processes that can mimic a tumor, such as meconium peritonitis (cystic type) [in utero. The estimated prevalence is about 0.29 per 10,000 live births and the mortality ranges from 11% to 50%. It usually appears in the neonatal period with abdominal distension, vomiting, acidosis and intra-abdominal calcifications.Meconium peritonitis is a sterile chemical peritonitis caused by meconium extruding into the peritoneal cavity through a small bowel perforation Perforation occurs most commonly in the ileum proximal to an obstruction, but this cannot always be demonstrated. The obstruction can be caused by atresia, stenosis, volvulus, internal bowel hernia, Meckel's diverticulum, meconium ileus, or peritoneal bands. Intestinal stenosis or atresia and meconium ileus account for 65% of the cases. Adhesions between loops of intestine and omentum act to contain the meconium collection extruded into the peritoneal cavity, creating a cystic mass that can be visualized on ultrasound. The reaction may alternatively result in the formation of a solid non-cystic mass with calcium deposits sealing off the perforation . When thIn a review of 12 cases of meconium peritonitis, intra-peritoneal calcifications were present in 60% of the patients with cystic fibrosis and 100% of patients without cystic fibrosis . The autCystic fibrosis is the most common fatal autosomal recessive disease among Caucasian population, with a frequency of one in 2000 to 3000 live births. The sweat chloride test remains the primary test for the diagnosis of this disease; the DNA testing is used for confirmation of patients with intermediate sweat chloride results. The sweat testing is performed by the collection of sweat with pilocarpine iontophoresis, and chemical determination of the chloride concentration . MeconiuDepending on when the bowel perforation occurs during development and the severity of the inflammatory reaction induced by the meconium extruded into the peritoneal cavity, three different types of meconium peritonitis can be described according to the ultrasound findings . The fibP < 0.022) [One study  has desc< 0.022) .Meconium pseudocysts are often accompanied by polyhydramnios . It is oThe MR appearance of meconium pseudocysts have been described in the literature ,12.With one exception, all cases of meconium pseudocyst were associated with bowel dilatation or free intra-abdominal fluid . In anotTreatment for meconium pseudocyst usually consists of surgical resection, although definitive procedures in the early neonatal period are usually difficult. Consequently, many patients require more than one surgical intervention. Some authors recommend immediate cyst drainage and decompression through paracentesis following birth with delayed definitive resection . The proMeconium peritonitis is an uncommon fetal and neonatal condition and it should be considered in the differential diagnosis when an echogenic intra-abdominal mass is observed. The prenatal appearance can be accompanied by signs of bowel obstruction, such as polyhydramnios and bowel dilatation. Generalized hydrops increases the severity of this disease.Surgery should be performed as soon as possible after delivery and initial resuscitation although immediate decompression paracentesis may result in a rapid improvement in the overall state of the newborn while preparation for surgery is underway. A two stage-approach with temporary enterostomy and delayed reversal is the best choice.Our case is unusual in comparison to other sonographically described prenatal cases due to the large size of the pseudocyst, the absence of ascites, bowel dilatation, or polyhydramnios, as well as a lack of abdominal calcifications in a newborn without cystic fibrosis.The clinical utility of this case is the recognition that meconium pseudocyst may present without typical ultrasound features, and should be considered in the differential diagnosis of an abdominal mass. This will facilitate delivery of appropriate treatment as soon as possible after birth.The authors declare that they have no competing interests.Written informed consent was obtained from the patient for both her case and the case of her child for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.EV collected the clinical case, wrote the manuscript, and conducted the literature search. DR collected previous similar clinical cases from the literature, drafted the manuscript, and attended the discussion. AV visited the patient, made the ultrasound diagnosis, and gave advice on the literature search. SC developed the article concept, provided ultrasound images and contributed to writing the introduction. JML provided general supervision and analyzed and interpreted the patient data. All authors have read and approved the final manuscript