Hapalemur alaotrensis have never been described in the literature. Even in more common species, such as dogs and cats, it is a very rare pathology. The description of this clinical case and its diagnostic management can be a valid clinical and anatomopathological support for other colleagues who face a similar case, so that they can focus on diagnostic investigations useful for diagnosis. A new anesthesiologic protocol, allowing the optimal management of the patient throughout the clinical procedure, is also reported in detail, as well as the detailed description of the lymphoCT examination. For all these reasons the authors think that the description of this clinical case can help other colleagues in the management of infested subjects.The clinical staff of the Veterinary Teaching Hospital of the University of Milan in Lodi have worked closely with veterinarians operating in a famous zoological park in Northern Italy. Thanks to this collaboration it has been possible to properly manage the clinical case reported in this brief communication. In veterinary medicine, clinical cases of chylopericardium in the species Hapalemur alaotrensis was evaluated following a history of dyspnea of 15 days’ duration. Thoracic radiography performed by the referring veterinarian revealed a large cardiac silhouette and dorsal deviation of the trachea. Heart sounds were muffled. Echocardiographic findings were indicative of severe pericardial effusion without cardiac tamponade. No pleural effusion was identified. A computed tomography (CT) exam confirmed the presence of severe pericardial effusion and allowed identification of a parenchymatous mediastinal lesion sited at the level of the left hemithorax. To delineate the thoracic duct, lymphoCT was also performed by injection of iodinated contrast medium in the perianal subcutaneous tissue. Pericardiocentesis yielded a considerable amount of effusion with chylous biochemical and cytological properties. A diagnosis of chylopericardium with absence of pleural effusion was made. Initially, the chylopericardium was managed conservatively with two centesis and oral treatment with prednisolone. Medical treatment did not result in complete resolution of effusion and clinical signs; therefore, subtotal pericardiectomy and thoracic duct ligation were recommended. After the second pericardiocentesis, the subject died and the pericardiectomy could not be performed. To the authors’ knowledge, this is the first report of the development of chylopericardium in a Hapalemur alaotrensis.An 11-year-old female  Chylopericardium generally occurs after thoracic surgery or trauma. Primary idiopathic chylopericardium is a rare condition, especially in captive zoo animals. A few case reports have been published on human primary idiopathic chylopericardium caused by leakage via an acquired fistula into the pericardium ,2,3.In human medicine, primary chylothorax and/or chylopericardium is rare and is mostly observed after mediastinal surgery. Although the exact pathophysiology of primary chylopericardium has not been established, the reflux of chylous fluid into the pericardial space was charged as a primary cause. Damage to the thoracic duct valves, and communication with the pericardial lymphatics or abnormally elevated pressure in the thoracic duct, could cause chylous fluid reflux ,5. FurthThe diagnostic algorithm of chylopericardium includes, primarily, a chest x-ray that shows an enlarged cardiac silhouette, and a subsequent echocardiography, which can explain the cause of cardiomegaly and pericardial fluid. Chest radiography and echocardiography are the first-line diagnostic tools with the addition of CT—useful to rule out any mediastinal disease that could cause compression and obstruction of the thoracic duct. Furthermore, imaging modalities that have been used to evaluate humans with primary idiopathic chylopericardium also include lymphangiography and lymphoscintigraphy ,10. HoweSome patients do not need surgical treatment, and they can be treated with conservative therapy and effective drainage, but a failure rate of 57–60% has been reported. In fact, the data presented by Reeves et al. (2019) provide no strong evidence in the literature for the use of medical therapy as a primary treatment method for idiopathic chylopericardium in dogs and cats . ThoraciHapalemur alaotrensis, weighing 1.7 kg, born and raised in captivity at “Natura Viva zoological park” in Bussolengo , was presented at the Veterinary Teaching Hospital of the University of Milan for dyspnea, tachypnea, and open-mouth breathing. No history of trauma or infection was reported by the keeper. The zoo veterinarian reported a chronic disease course of three weeks, which initially presented with lethargy, decreased activity, weakness, and malaise. Physical examination showed respiratory distress, hypotension, and muffled heart sounds. To perform clinical procedures, general anesthesia was necessary. For this reason, it was not possible to record the basal vital parameters of the subject. An 11-year-old female −1 , Italy), ketamine at 5 mg kg−1 , Italy), and methadone at 0.2 mg kg−1 , was performed. After premedication, heart rate was 80 bpm, breathing rate varied between 40 and 50 bpm, and temperature was 38.2 °C. A 22 G venous catheter , Italy) was placed in the left cephalic vein, and general anesthesia was induced with propofol , Italy) at 2 mg kg−1. Orotracheal intubation was achieved with a 3.5 mm diameter tube, and general anesthesia was maintained with isoflurane , titrated to effect, and delivered in oxygen at 100%. Every five minutes the depth of anesthesia was assessed, and the isoflurane vaporized settings were readjusted to achieve an adequate depth of anesthesia, characterized by absent palpebral reflex, ventromedial eye position, and relaxed jaw tone. During anesthesia, the patient presented discordant breathing, although the pulse oximeter detected oxygen saturation between 98 and 100%. Despite the lack of literature on pulse oximeter validation in this species, these values can be considered physiologic, as Hapalemur alaotrensis belongs to the mammalian group [Intramuscular premedication, with dexmedetomidine at 20 μg kgan group .Blood samples obtained from the sedated patient, from the lateral saphenous vein, were largely unremarkable except for a mild lymphopenia  and increased hematocrit . It was not possible to compare albumin, cholesterol, and triglycerides measurement results with any published data . Complete blood count (CBC) was performed with the automated hematology analyzer Sysmex XT-2000iV  using the “monkey” profile supplied by the instrument’s multispecies software . BiochemChest and abdomen radiograms in right lateral and dorsal recumbency revealed a severely enlarged cardiac silhouette, which occupied the thoracic cavity from the third to the tenth pair of ribs, touching the thoracic wall bilaterally. It caused severe dorsal deviation of the trachea, lung, and diaphragmatic compression .Emergency echocardiography and echo-Doppler examinations, but not a thoracic focused assessment with sonography for trauma (T-FAST) evaluation, were performed, according to the American Society of Echocardiography guidelines, with an Esaote device (My Lab 50 Gold Cardiovascular) and a multifrequency phased-array transducer 7.5–10 MHz) . No echo MHz . NoA cytological examination was performed on smears obtained both with line preparation and cytocentrifuge methods, and stained with May–Grunwald Giemsa. The cellular content of the fluid was of 3.43 × 103 nucleated cells/µL. Within a moderate hematic background, a mixed cell population consisting predominantly of small lymphocytes (85%), macrophages often containing hemosiderin, erythrocytes, and lipid droplets (10%) was identified; neutrophils, eosinophils, and plasma cells were also present in the fluid to a lesser extent (5%). No evidence of cytologic malignancies was identified . The bio®, General Electric Healthcare, Milano, Italy); whole body images were acquired before and after intravenous administration of non-ionic iodinated contrast media . The CT scan revealed severe, homogeneous, non-enhancing, pericardial effusion (12 HU) and mild right pleural effusion that caused severe ventral lung compression. A cranial mediastinal mass was identified close to the thoracic wall, left-sided, localized at the level of the second intercostal space, ellipsoid-shaped (1 × 1.4 × 1.4 cm), with well-defined margins, soft tissue attenuation, and heterogeneously enhanced . Given the herbivorous nature of the patient, no dietary therapy with a restrictive diet was established. For the first fifteen days the subject did not manifest dyspnea, but then the clinical signs reappeared, and the animal was returned to the Veterinary Teaching Hospital. Despite the steroid therapy, during the second echocardiographic control the presence of abundant pericardial fluid was still evident. About 70 mL of pericardial fluid was drained through pericardiocentesis. During the second echocardiographic control, it was possible to perform an ultrasound-guided cytology of the mediastinal mass, but the cytological examination was inconclusive. The subject died spontaneously one week after the second pericardiocentesis.The day after pericardiocentesis and the CT scan, oral prednisolone therapy was started at 0.5 mg/kg twice daily until clinical control  on a pericardial effusion sample. This research has not demonstrated the presence of this causative agent (Cardiovirus).Hapalemur alaotrensis. Furthermore, this is the first description of clinical use of CT lymphography of the thoracic duct by perianal subcutaneous injection of iodinated contrast medium in a lemur. To the authors’ knowledge, this is the first report that describes the anesthetic protocol and the diagnostic trial for the diagnosis of chylopericardium in a Unfortunately, no migration of subcutaneously injected contrast medium was observed, and it was not possible to identify the thoracic duct nor any connection between it and the pericardial sac. This is likely attributable to limitations of the lymphoCT procedure rather than the absence of a connection between these two structures. In fact, in our experience we observed migration of contrast medium in almost half of the patients (dogs and cats) that underwent CT lymphography of the thoracic duct by perianal subcutaneous injection of iodinated contrast medium. In conclusion, this case report confirms that it is possible that chylopericardium is a self-perpetuating condition for which pericardial effusion may lead to a chronic increase in right-sided venous pressure that prevents the normal forward flow of chylous into the cranial vena cava. The final diagnosis was performed by pericardial fluid analysis, and unfortunately, it was not possible to detect a rupture of the thoracic duct through the additional diagnostic investigations described. Furthermore, the conservative therapy and the effective drainage resulted in a therapeutic failure, superimposable to a failure rate of 57–60% reported for this kind of approach.We believe that the described procedures, the anesthesiologic protocol, the cytological examination of the effusion, the CT examination, and the anatomopathological description may be useful for the colleagues who are faced with the management of a case of chylopericardium in unconventional species.


Eosinophilic gastroenteritis (EGE) is an extremely rare disease of unknown aetiology that can occur at any age, but rarely in children. It usually presents with ambiguous abdominal pain and the symptoms can occur for years before diagnosis. It needs a high suspicion and therefore misdiagnosis can occur.We present a case of three-and-a-half year old girl who had a complicated EGE but was misdiagnosed as no proper consult was available as she presented in a remote medical centre. She had 50 cm from her small intestine dissected as micro abscesses and a necrotic mass of 3.5*2.5 cm were observed.EGE is usually managed medically. However, the patient’s condition was complicated and surgery was indicated. However, if proper diagnosis was made, conservative surgery would be the proper management as this case tends to improve with steroids.Medical centres in remote areas should have a way to discuss atypical cases with a skilled consultant even when urgent as surgery indication can completely differ. This is the first case reported in the region with EGE in a child which can justify the difficulty in diagnosis as it is quite rare and have not been reported previously in the region which can lead to futuristic misdiagnosis. We pr29 per L , haemoglobin level of 10.6 g/dL, and CRP of 94.2 mg/L. Platelets count, electrolytes, creatinine, urea, liver function tests, and Widal and Wright tests were all normal. Urine test showed 12–14 white blood cells with + oxalate level. Ultrasonography showed free fluids in the Morison’s pouch in the abdomen and an epileptic mass was observed within the small intestine. It was suspected to be intussusception with a size of 2.5*3.5 superiorly to the umbilicus and to the right (A 42-month-old girl presented to the emergency department as she had recurrent abdominal pain for one week, upper to the umbilicus region. This pain continued for 30 min at a time, but then became continuous. She reported having fever and chills. The pain woke her up at night without any particular position that relieved her pain. The patient had recurrent sour vomiting without any relief. Passing gases and stools did not relief the symptoms and she had no diarrhoea. Past and family history was unremarkable except for asthma in the grandmother. The patient had no food or any other allergies. On examination, the patient weight and height were normal according to her age. She had generalised tenderness over the abdominal area without organomegaly. Bowel movements were normal. Rectal examination showed no stool. Her labs showed a high white cell count of 29,000 * 10he right . The reshe right  found puhe right , Fig. 2.3Pathology for EGE shows infiltration of eosinophils to the bowel wall and more than 20 eosinophils/HPF can be seen in at least one focus. Furthermore, necrotising granulomas, prominent vessels, and vasculitis can be seen and usually without other type of inflammatory cells . The diaIn conclusion, EGE is a rare disease which requires a strong suspicion to be diagnosed. However, in our case the atypical imaging made the diagnosis very difficult before surgery which emphasises the importance of imaging before surgery, especially with no experienced health workers to give the proper consultants like in remote areas. EGE should be suspected in acute abdominal pain as surgery can be avoided. This is the first case of paediatric EGE and second overall in the Middle East which makes this case quite unique.No conflict of interest to declare.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Damascus University deanship ethical approval was taken for this research.Consent for using and publishing data from the patient’s guardian was taken for this case report.Ameer Kakaje.Not commissioned, externally peer-reviewed.Ameer Kakaje: Conceptualization, Formal analysis, Software, Writing - original draft, Writing - review & editing. Noha Hedar: Methodology, Visualization, Validation, Investigation, Writing - original draft, Project administration. Najat Alali Alahmad: Resources, Supervision, Investigation, Writing - review & editing.


Suprasellar meningiomas make a relevant differential when it comes to sellar/suprasellar masses. The most common pathology in this location is pituitary adenomas. It is imperative to differentiate the two entities based on imaging as the clinical picture, and sometimes the biochemical profile can show significant overlap. It is also essential for the neurosurgeons to have a preoperative diagnosis as the behavior of both tumors is different. This piece will give a pictorial review of the imaging features of suprasellar meningiomas, in patients who presented to us with sellar/suprasellar masses. The aim is to help the radiologists as well as fellow clinicians to diagnose this entity with confidence based on imaging. Meningioma accounts for 15-25% of all intracranial tumors . MeningiRadiologically contrast-enhanced magnetic resonance imaging plays a defining role in evaluating the extent of a tumor. It gives accurate guidance to and within the sella, provides precise information about the extent of resection, and alert the surgeon to the development of complications.Meningiomas are generally highly vascular tumors that obtain their blood supply from the arteries of the adjacent dura and bone, therefore, there is a high risk of intraoperative bleeding . In thesCase 1The first patient was a 54-year-old female who presented with a chief complaint of headache that worsened over time. The pain was relieved by pain killers temporarily. There were also complaints of decreased vision, more in the right eye, which worsened over time. On examination, there was an almost complete loss of right temporal field vision. No visual field loss was identified on the left side. Her hormonal profile was unremarkable apart from suppressed thyroid-stimulating hormone (TSH). However, there were no clinical signs of thyroid overactivity. A thyroid scan was performed, which showed a hyperfunctioning multinodular goiter. Initial MRI was a non-targeted study, raising suspicion of pituitary macroadenoma. A repeat targeted MRI at our hospital showed a large sellar/suprasellar mass involving the tuberculum sellae. The tumor extended anteriorly over the planum sphenoidale. Posteriorly, the tumor involved the pituitary fossa compressing the normal pituitary, and the interpeduncular cistern. There was a significant mass effect and displacement of optic chiasm superiorly. MRI signals were isointense to gray matter on T1- and T2-weighted sequences, with intense homogenous postcontrast enhancement, suggestive of meningioma. The tumor was encasing bilateral internal carotid arteries , which raised suspicion of pituitary adenoma. MRI showed an avidly enhancing soft tissue in the left parasellar and sellar region, with the involvement of the pituitary fossa. The pituitary had homogenous enhancement and was compressed along the right sellar wall, and the pituitary stalk displaced towards the right. The dural tail was along the left lateral aspect of the tumor, with the involvement of the left internal carotid artery, and partial encasement of the left anterior cerebral artery. It had a mild mass effect and encasement on the left optic nerve and optic chiasm Figure . She gotCase 4The fourth patient who had a diagnostic scan performed elsewhere reported at our institute was a 70-year-old female with a complaint of right eye loss of vision. MRI performed, showed a suprasellar enhancing tumor at the tuberculum sellae. There was compression of the pituitary gland showing uniform enhancement. There was encasement of the right anterior cerebral artery with the involvement of the optic chiasm Figure .Meningiomas originate from the meningocytes and arachnoid cap cells . MRI is Meningiomas in suprasellar and parasellar regions can be further divided depending on their site of origin, planum sphenoidale, tuberculum sellae, or diaphragmatic sellae. These tumors are common in females with a female to male ratio of 6:1. The mean age documented in the literature is 52 years , our cases also fall in this age category [Meningiomas are extra-axial masses, most of them display all the imaging features of an extra-axial tumor, including CSF cleft, displacement, and mass effect on the underlying brain cortex .Meningiomas, like suprasellar macroadenoma, are often isointense to cortical gray matter on T1-weighted images . On T2-wPre-surgical diagnosis of meningiomas is imperative because of their fibrous content and expression of angiogenesis factors, making them tenacious and exceptionally vascular. It can lead to significant intra and perioperative morbidity and mortality secondary to hemorrhage compared with pituitary adenomas . AlthougSellar and suprasellar meningiomas represent a significant group of intracranial tumors. The surgical treatment presents several difficulties as they are well known to involve critical neurovascular structures. Because meningiomas are so common, the radiologist must be aware of their less frequent and uncharacteristic imaging features to suggest the correct diagnosis in atypical cases.


Juxtapapillary retinal capillary hemangioblastoma (JRCH), a benign intraocular vascular tumor, is usually progressive and may lead to severe vision loss due to various complications. We herein present a case of JRCH observed with laser speckle flowgraphy (LSFG) before and after laser photocoagulation (LPC). A 21-year-old Japanese woman underwent LSFG evaluations. Right eye showed an orange-colored tumor consistent with JRCH on the papillomacular bundle, where LSFG showed a mild warm-color blood flow signal. Eight months after the first examination, JRCH in the right eye increased redness with vasodilatation, and the size enlarged, where LSFG showed a stronger warm-color blood flow signal. She underwent direct yellow laser ablation for the JRCH lesion. One week after LPC, JRCH became paler and LSFG eventually depicted a weakened blood flow signal at the same site. In conclusion, non-invasive and reproducible LSFG is a useful tool for assessing not only JRCH activity but also therapeutic effect. Juxtapapillary retinal capillary hemangioblastoma (JRCH), a benign intraocular vascular tumor, arises on or adjacent to the optic nerve head . JRCH maLaser speckle flowgraphy (LSFG) is a blood flow imaging device based on laser scattering, which non-invasively allows for two-dimensional visualization of fundus circulation in various intraocular mass lesions such as optic disc melanocytoma , choroidA 21-year-old Japanese woman complained of blurred vision in her left eye and was referred to our clinic because of fundus lesions. She was diagnosed with JRCH oculus sinister (OS) at the age of 8 when she was pointed out to have poor visual acuity at school health check. At that time, she underwent brain magnetic resonance imaging and echocardiography, proving no abnormalities. At the doctor’s discretion, her left eye was observed without treatment until age 14, and she suspended her visits. She had a history of schizophrenia with no family history of any other disorders including VHL disease. Her best-corrected visual acuity (BCVA) was 1.0 oculus dexter (OD) and 0.02 with disuse exotropia OS, and her intraocular pressure was normal oculi uterque (OU). Slit-lamp microscopy did not detect any findings OU. The patient received multimodal imaging evaluations including funduscopy, swept-source optical coherence tomography (SS-OCT), fluorescein angiography (FA), and LSFG, together with systemic examinations such as whole body magnetic resonance imaging. The institutional review board of Hokkaido University Hospital waived ethical assessment of this clinical study because of a single case report. This study adhered to the tenets of Declaration of Helsinki.Color fundus photography (CFP) revealed an orange-colored endophytic tumor adjacent to the temporal optic disc OD . The tumA systemic examination revealed multiple vascular tumors involving the spinal cord, medulla oblongata, and kidney. Histopathology of the tumor in the spinal cord revealed hemangioblastoma. Based on the above findings, she was clinically diagnosed with suspected VHL disease. Eight months after the first examination, JRCH became enlarged to 1.64 × 1.36 mm with marked redness due to vasodilatation . LSFG shAfter informed consent was obtained, she underwent direct yellow laser ablation of the JRCH lesion . One week after LPC, JRCH became paler with its size measuring 1.80 × 1.71 mm , and a wThe present study demonstrated novel findings on JRCH observed with LSFG, so as to better understand blood flow changes in JRCH before and after LPC. To the best of our knowledge, this report is the first to show vascular obstruction and blood flow reduction in JRCH following LPC by means of LSFG monitoring.In general, the clinical course of JRCH can deteriorate, thereby causing various complications such as macular edema, retinal exudation, epiretinal membrane formation, and retinal detachment . As concIn our case, the right eye was observed without any previous treatments at the first visit when CFP showed an orange-colored tumor and SS-OCT demonstrated a mildly elevated lesion. In addition, LSFG showed a mild warm-color blood flow signal corresponding to JRCH. JRCH was followed up by assessing biomicroscopic, SS-OCT and LSFG findings. After 8 months of follow-up, the color of the tumor increased redness with vasodilatation, the size enlarged on CFP, and the height was elevated on SS-OCT. Although hyperfluorescent findings depicted with FA were not obviously different between before and after the exacerbation, LSFG clearly detected an enhanced warm-color blood flow signal at this time. This means that LSFG more clearly showed hyperperfusion signals when the tumor activity worsened, in contrast to FA findings. Taken together, the blood flow signals on LSFG changed with time during the exacerbation, indicating that LSFG was important for evaluating tumor activity.In our case, FA detected hypofluorescent spots in the LPC-treated area, which coincides with the low blood flow area on LSFG. Although FA findings were consistent with LSFG findings, it was unclear to what extent the tumor body had lost blood flow, due to hyperfluorescence surrounding hypofluorescence. Indeed, Sagar et al. described the shortcomings of FA as follows: tumors captured in the early phase of FA show well-defined borders, whereas tumors captured in the late phase are ill-defined due to obscuration of margins by dye leakage . In contIn addition to FA, OCT angiography (OCTA) has been increasingly regarded as a useful tool to monitor response to JRCH treatment , 10–12 aBesides LPC, there are several other treatment options for JRCH such as intravitreal anti-VEGF therapy and PDT . As concAs for histopathological findings, JRCH is known to be composed of endothelial cells, pericytes, and foamy stromal cells . The proIn conclusion, we reported a case of JRCH treated with LPC and observed LSFG findings at baseline and before and after LPC. LSFG is useful for evaluating not only tumor activity but also therapeutic efficacy, which may play an important role in the management of JRCH.


T2 weighted imaging. No metastasis or lymph node swelling was detected. Based on the hypervascularity of the tumour, the pre-operative diagnosis was pancreatic neuroendocrine tumour with splenic invasion. The patient underwent laparoscopic distal pancreatectomy with splenectomy. The pathological diagnosis was microcystic serous cystadenoma with locally aggressive features . A few cases of pancreatic serous cystadenomas with splenic invasion have been reported; all were symptomatic, with diameters greater than approximately 9 cm. This is the first known case of incidentally detected serous cystadenoma with splenic invasion, reported with detailed imaging findings of dynamic CT and MRI.Serous cystic neoplasms are relatively uncommon and rarely possess malignant potential. We report a rare case of pancreatic serous cystadenoma with splenic invasion in a female in her 60s. Dynamic contrast-enhanced CT revealed a 3 cm mass in the tail of the pancreas. The lesion showed marked enhancement in the arterial phase on dynamic CT, which extended into the spleen. No cystic components were detected in the pancreatic mass on either magnetic resonance cholangiopancreatography or  A female in her 60s, with no significant medical or family history, underwent an annual medical check-up at a different hospital and was diagnosed with diabetes mellitus. An abdominal ultrasonography screening revealed a hypoechoic mass in the tail of the pancreas. Physical examination, laboratory studies that included tumour markers , and hormonal examination  all revealed normal results. The patient was referred to our hospital for further examination and treatment.T2 weighted MRI, the mass in the tail of the pancreas showed slightly high signal intensity, compared with the pancreatic parenchyma and spleen  values (1.63 × 10−3 mm2/s) than the pancreatic parenchyma (1.40 × 10−3 mm2/s). Based on these imaging findings, we suspected a pancreatic neuroendocrine tumour (pNET) with splenic invasion.Endoscopic ultrasonography revealed a homogenous hypoechoic mass in the pancreatic tail. Honeycomb structure was not observed. Dynamic contrast-enhanced CT revealed a 3 cm lobulated mass in the tail of the pancreas . The masd spleen . On magnLaparoscopic distal pancreatectomy with splenectomy was performed. Macroscopically, a well-circumscribed tan-pink tumour, measuring 26 × 22 × 28 mm in size, was located in the tail of the pancreas. The tumour directly invaded the spleen . Cysts c1 and Hodgkinson2 in 1978. Approximately 75% of SCNs occur in females ranging between 26 and 89 years of age .3 Almost 60% of SCNs are seen in the body or tail of the pancreas. Since patients are typically asymptomatic (61%), SCNs are usually identified incidentally.4Serous cystic neoplasms (SCNs) are relatively uncommon, accounting for 1–2% of all pancreatic neoplasms, and were first reported by Compagno4 The majority of cases (45%) have a macroscopic morphology characterised by innumerable small cysts, each typically less than 2 cm in diameter (microcystic type).4 The cysts are generally arranged in a honeycomb pattern, with thin internal enhancing septations which show low signal on T2 weighted images.5 A fibrous central scar with or without a stellate pattern of calcifications is detected in approximately 30% of cases.5 The central scar shows low signal intensity on T2 weighted images.5 Macrocystic type, which is the second most common type (32%), is composed of a few large cysts, each more than 2 cm in diameter.4SCNs are morphologically classified into four types: microcystic, macrocystic, solid, and mixed type.6 The incidence of solid type was reported to be only 5% of SCNs.4 Compared with the microcystic type, the solid type has a homogenous appearance and is formed by cysts that are so small that the cystic structures cannot be macroscopically identified. The smaller the size becomes of each cystic component, the more difficult it is to identify them on imaging examinations. Therefore, solid type is often misdiagnosed as other solid hypervascular tumours, including pNET and metastatic renal cell carcinoma.7 Prior to the final diagnosis of microcystic serous cystadenoma, we preoperatively misdiagnosed the current case as pNET because the pancreatic tail mass appeared as a solid tumour with hypervascularity on dynamic CT and MRI. Based on the imaging and macroscopic findings, the tumour type was almost similar to solid type.Solid type SCN has a solid gross appearance, and the cells are arranged in small acini with no or minute central lumina.i.e. serous cystadenocarcinoma), regardless of nuclear atypia or local invasion.6 Galanis et al reported that the malignant potential of SCNs was low (2/158 cases).3 In the present case, the tumour was considered as benign since no distant metastasis was detected. However, distant metastasis might be metachronous (up to 10 years) in serous pancreatic tumours,3 which suggests that our patient will need a long follow-up period. Even in malignant cases, death is quite rare .8 Serous cystadenomas have also been reported to invade various organs and tissues, including the duodenum, vessels, nerves, stomach, adrenal gland, spleen, and/or colon.9 None of these cases were metastatic to the liver or other distant organs, and none of the patients died; these patients were predominantly female , with mean age of 55 years, which is younger than that of non-invasive serous cystadenomas.9 In a multivariate analysis of 257 patients who underwent surgical resection of SCNs, tumour diameter and location of the tumour in the pancreatic head were independently associated with aggressive behaviour. The mean diameter of aggressive tumours was 10.5 cm .10 In a few cases, the relatively small tumours were reported to invade the surrounding tissues such as a 2.5 cm tumour with vascular and perivascular invasion,11 a 3.5 cm tumour with large vessel invasion,10 a 4 cm tumour with lymph node invasion,10 and a 4 cm tumour with neural and lymph node invasion.12According to the current WHO classification, only a case with unequivocal distant metastasis beyond the pancreatic/peripancreatic bed is defined as a malignant SCN . However, in the present case, a relatively small pancreatic mass (3 cm in diameter) was detected in an asymptomatic patient. To the best of our knowledge, this is the first case of incidentally detected serous cystadenoma with splenic invasion, reported with detailed imaging findings on dynamic CT and MRI.Only eight cases of serous cystadenomas with splenic invasion have been reported in English-language literature .9,10,13–In conclusion, the current report presents a rare case of microcystic serous cystadenoma with splenic invasion, with a small mass that was detected incidentally. It is important to recognise that pancreatic serous cystadenomas can show locally aggressive features, even if they are small in size, and that they have a limited malignant potential with a favourable prognosis.Serous cystadenomas of the pancreas can show invasive growth into the surrounding tissues, even if they are small in size.Serous cystadenomas of the pancreas with locally aggressive features tend to have a favourable prognosis, according to previous reports.


Perforating granuloma annulare (PGA) is a rare inflammatory condition characterized by transepithelial elimination of necrobiotic collagen with granulomas in the dermis. It commonly presents as umbilicated papules or pustules on the extremities and dorsal hands. The distribution of PGA can be described as generalized or localized, with only 9% of patients presenting with a single lesion. Herein, we report an unusual presentation of PGA as a single localized plaque on the forearm that resembled psoriasis. Granuloma annulare (GA) is a benign, granulomatous condition that presents with annular papules on the hands and feet . One rarA 67-year-old man presented with a tender plaque on the dorsal left forearm that gradually progressed in size over a one-month period. The patient had not previously been treated with any topical or systemic treatments. Past dermatologic history included multiple actinic keratoses on the scalp and back treated with cryotherapy and topical 5-fluorouracil. His other medical history includes for hypertension and well-controlled type II diabetes mellitus.Physical exam revealed a single asymmetric pink tender plaque with overlying scaling and crusting on the left forearm. Other exam findings included scattered seborrheic keratoses on the trunk. The initial clinical suspicion was between inflammatory dermatoses, such as atopic dermatitis or contact dermatitis, and psoriasis. The patient was first treated with 0.1% triamcinolone ointment. After one month, repeat examination revealed progression of the tender pink plaque, which was measured to be approximately 2.5 x 4 cm (Figure Histopathologic examination of the shave biopsy demonstrated pseudoepitheliomatous hyperplasia of the epidermis and trans-epidermal elimination of granulomas Figure . GranuloOverall, the histopathologic features were consistent with a diagnosis of PGA. The patient was made aware of the diagnosis one week after the visit and treatment regimen of halobetasol propionate and tazarotene ointment was continued while waiting for a follow-up appointment. Follow-up was delayed due to stay-at-home orders and had not been yet conducted at the time of article publication.PGA was first described in 1971 in two patients with lesions on the hands. Histopathology demonstrated perforation of the epidermis by necrotic material and dermis granulomas, and the new term PGA was coined . Since tHistopathologic features of PGA include granulomas with multinuclear histiocytes arranged in a diffuse or palisading pattern around a trans-epidermal protrusion of necrotic collagen . The difPGA is classically described as flesh to red-colored umbilicated papules or pustules ranging from 1-5 mm. These papules often have an overlying scale, crusting, or exudate, and are often arranged in an annular form . The disTreatment options for PGA includes complete excision, psoralen, and ultraviolet A therapy, intralesional triamcinolone, and high-dose corticosteroids ,7. SpontPGA is a rare skin condition that can uncommonly present as a single painful psoriasis-like plaque. In our patient, the diagnosis was made by histopathologic examination after the lesion failed to respond to empiric anti-inflammatory therapy. Clinicians should be aware of this unusual presentation of localized PGA and have a low threshold for biopsy when refractory to conventional therapy.


Solitary adrenal metastasis derived from colorectal cancer is rare. Adrenal metastasis is usually associated with systemic spread of the disease and is considered to be unsuitable for surgical resection. However, it has been reported that an aggressive surgical resection of adrenal metastasis results in improved overall survival in selected patients. We herein report an extremely rare case of complete resection of rectal cancer with a synchronous solitary adrenal metastasis.A 70-year-old woman who presented with bloody stool was diagnosed with rectal cancer with a synchronous solitary adrenal metastasis and was suspected of having liver invasion. After a total of 2 cycles of chemotherapy with capecitabine and oxaliplatin, an abdominoperineal resection with D2 (proxD3) lymph node dissection and right adrenalectomy was performed and complete resection was possible. According to the TNM classification, the diagnosis was stage IVA (fT3N1bM1a[ADR]). At 18 months after surgery, the patient is alive with no evidence of recurrence and distant metastasis.Complete resection of adrenal metastasis may have a possibility of leading to a good prognosis in patients with a synchronous solitary adrenal metastasis.Adrenalectomy should be considered in patients who can undergo complete resection, as it may offer a good long-term prognosis. Adrenal metastasis usually associated with systemic spread of the disease and is considered to be unsuitable for surgical resection. However, it has been reported that an aggressive surgical resection of adrenal metastasis results in improved overall survival in selected patients . We here2A 70-year-old woman presented with bloody stool. She had a 2-month history of blood in her feces but without abdominal pain or any relevant past or family history. A colonoscopy revealed a type 2 tumor in the rectum and subsequent biopsy specimens were obtained. Histopathological examination showed a moderately differentiated adenocarcinoma of rectal origin with RAS mutation. Her serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were 13.6 and 129.6 ng/mL, respectively. Other laboratory data showed no abnormalities. A computed tomography (CT) scan revealed circumferential thickness of the rectum and an enlargement of the right adrenal gland with a size of 26 mm; the patient was suspected of having liver invasion . There w3Although there is no clear evidence of survival benefit for surgical resection of adrenal metastasis derived from colorectal cancer, it has been reported that adrenalectomy may improve long-term outcomes. Vazquez et al. reported that an aggressive surgical approach results in improved overall survival in patients with adrenal metastasis derived from soft tissues, kidney, lung, and pancreas. Other tumors may benefit from such approach . Muth etA similar case report in Japan found that, out of 53 cases of adrenal metastasis derived from colorectal cancer, 18 cases were solitary adrenal metastases, and the other cases were part of systemic metastases . FourteeThe present report was associated with a few limitations. The observation period was rather short and the number of cases was too small to examine the long-term prognosis. In the future, it is expected that a larger cohort of adrenal metastasis cases will be collected and the long-term prognoses will be clarified.4Adrenalectomy should be considered in patients who can undergo complete resection, as it may offer a better long-term prognosis.The authors declare no conflicts of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This report was reviewed and approved by the Institutional Review Board of JA GIFU Kouseiren Ibi Kosei Hospital.Informed consent was obtained from the patient for publication of this case report.Hirokatsu Hayashi: Data Acquisition, Data Interpret and writing of the manuscript.Yusuke Murase & Hitoya Sano e: management of case.Kimitosi Nishio: Supervision, review and editing.Iwao Kumazawa: Supervision, review, editing, and final approval of the version to be submitted.NA.The Guarantor is Hirokatsu Hayashi.Not commissioned, externally peer-reviewed.


Esophageal window defect in patients with esophageal resection could be challenging to repair. In this case report, a free posterior tibial artery perforator flap (FPTAPF) was used for semi-circumference patch esophagoplasty.For this 47-year-old male patient with recurrent laryngeal nerve schwannoma invading cervical and upper thoracic esophagus, cervical and upper thoracic esophageal reconstruction following tumor resection was neededPathologic result demonstrated recurrent laryngeal nerve schwannoma. Ultrasound examination detected a tumor (7 cm × 6 cm × 3 cm) located behind the right thyroid lobe, and contrast-enhanced computed tomography scan revealed that tumor was located between the cervical esophagus and trachea, and compressed these structures.The tumor had a size of 7 cm × 6 cm × 3 cm, and the semi-circumference defect of the cervical and upper thoracic esophagus was about 7 cm in length after complete tumor resection. A 7 cm × 4 cm FPTAPF was designed and harvested for esophageal reconstruction.The posterior tibial flap survived well and satisfactory recovery of esophageal function was obtained with no significant complications. No local tumor relapse was indicated by computed tomography during the 2-year postoperative follow-up.This case highlights the stable performance of FPTAPF when used for the reconstruction of large esophageal window defect. However, esophageal defect after esophageal window resection could be too large to be reconstructed directly by traditional methods .,3 Until now, this constructive procedure has been a great challenge for head and neck surgeons. Owing to bulky volume, the pedicled flap was difficult to reconstruct the esophageal defect. The tubular autografts  were widely used for esophageal reconstruction. Nevertheless, these autografts utilized to reconstruct the circumferential esophageal defect might not be suitable for larger esophageal window defect. Additionally, the harvest of autograft is time consuming and more technical demanding.,6 Compared with free radial forearm flap, the free posterior tibial artery perforator flap (FPTAPF) with similar tissue properties and hidden scar has been used to reconstruct the head and neck defect. Here we report a case in which the FPTAPF was used for the reconstruction of large esophageal window defect caused by resection of recurrent laryngeal nerve schwannoma invading esophagus.Schwannoma rarely originates from recurrent laryngeal nerve in clinical practice.2A 47-year-old male patient with neck mass for 3 years, progressive dysphagia lasting over 6 months and difficulty breathing after exercise for more than 1 month was referred to our department. Ultrasound examination detected a tumor (7 cm × 6 cm × 3 cm) located behind the right thyroid lobe. Preoperative biopsy indicated a spindle cell tumor. Contrast-enhanced computed tomography scan revealed that the tumor was located between the cervical esophagus and trachea, and compressed these structures  originated from the right recurrent laryngeal nerve and invaded the esophageal mucosa Fig. A, B. ThePassing through the hypopharynx and down into the distal esophagus, a nasogastric tube was inserted. A FPTAPF with the size of 7 cm × 4 cm, was designed and harvested to reconstruct the esophageal window defect Fig. A. Once tThe operative time of the procedure was about 3 hours. The flap survived well postoperatively with no operation-related complication observed. Postoperative pathological examination results showed that the tumor was a recurrent laryngeal nerve schwannoma, and invaded the esophageal mucosa. Oral feeding and normal diet were resumed on postoperative day 22 and day 35, respectively. Satisfactory recovery of swallowing function was gained. The patient was weaned from tracheostomy on postoperative day 60. An excellent function of the reconstructed esophagus was observed by esophagography on postoperative day 90 Fig. A and no The report was approved by the Institutional Review Board of West China Hospital. Written informed consent was obtained from the patient for publication of this case report and accompanying images.3 which mainly arise from the sympathetic nerve. In the present case, schwannoma arising from the right recurrent laryngeal nerve, is quite rare. Therapeutic management is mainly based on surgery. However, when giant recurrent laryngeal nerve schwannnomas invaded the esophagus, the reconstruction of large esophageal window defect after extensive tumor resection would be a great challenge. The esophagus should be reconstructed to restore its integrity after partial resection.As a benign neurogenic tumor, schwannnomas arise from schwann cells surrounding peripheral nerves and up to 45% of schwannomas occur in head and neck region,,8 However, such thick free or pedicle flaps might not be feasible for repairing defects in the narrow space around esophageal defects under the preservation of larynx and trachea. Therefore, thinner free flaps remain a better choice for the reconstruction of large esophageal window defects. Free radial forearm flap and adipofascial anterolateral thigh free flap have been used to reconstruct esophageal defects, but not semi-circumference ones, and satisfactory reconstruction of esophageal function was obtained.,8 It has been reported that free posterior tibial artery perforator flaps have several unique advantages. The constant vascular anatomy on the medial surface of shank of septocutaneous perforators of posterior tibial artery makes its access much easier than other fasciocutaneous flaps. More importantly, a FPTAPF can also provide similar tissue properties to a free radial forearm flap, which has been widely and successfully used in reconstruction. In addition, compared to free radial forearm flap, FPTAPF with hidden scar of flap donor region has incomparable advantage for aesthetical consideration.,11 Meanwhile, FPTAPFs have the potential of reconstruction of larger defect than radial forearm flap. We have reported in a case report that, FPTAPF, specifically a free bipaddled posterior tibial artery perforator flap with size of 12 cm × 9 cm was successfully used for simultaneous tracheal and esophageal reconstruction for thyroid cancer involving trachea and esophagus. However, patients with severe peripheral artery disease or varicose veins of the lower limb were not suggested to undergo FPTAPF surgery.In recent decades, the pedicled and free flaps  were widely used to reconstruct hypopharyngeal and esophageal defects.In the current case, we described a novel use of FPTAPF for semi-circumference patch esophagoplasty in a patient with recurrent laryngeal nerve schwannoma invading cervical and upper thoracic esophagus, which was under different situation with previously reported case in terms of tumor and invasion status. As a result, the posterior tibial flap survived well, and esophageal function was recovered with no significant complications. We believe that this case might stable performance of FPTAPF when used for the reconstruction of large esophageal window defect.Conceptualization: Jun Liu, Jifeng Liu, Jianjun Ren, Linke Li, Fei Chen.Data curation: Jifeng Liu, Jianjun Ren, Ji Wang, Dan Lv, Di Deng, Linke Li, Fei Chen.Formal analysis: Ji Wang, Dan Lv.Funding acquisition: Jun Liu, Fei Chen.Investigation: Jun Liu, Ji Wang, Di Deng, Linke Li, Fei Chen.Methodology: Jun Liu, Jifeng Liu, Jianjun Ren, Ji Wang, Dan Lv, Di Deng, Linke Li, Fei Chen.Resources: Di Deng.Supervision: Jifeng Liu, Jianjun Ren, Fei Chen.Validation: Dan Lv.Writing – original draft: Jun Liu, Jifeng Liu, Jianjun Ren, Dan Lv, Fei Chen.Writing – review & editing: Jun Liu, Jifeng Liu, Jianjun Ren, Di Deng, Fei Chen.


Superficial arteriovenous fistulae in the absence of other complicating features can be easily treatable with simple surgical excision. In this case, the patient's troublesome symptoms were completely cured with a straightforward procedure. Superficial arteriovenous fistulae in the absence of other complicating features can be easily treatable with simple surgical excision. In this case, the patient's troublesome symptoms were completely cured with a straightforward procedure. An arteriovenous fistula (AVF) is an abnormal connection between an artery and a vein. Commonly, AVFs are surgically created as a means of vascular access for hemodialysis; however, they have also been reported to occur congenitally, as a result of trauma or iatrogenic injury, and in some cases spontaneously. The authors report an unusual case of a spontaneous AVF between the posterior auricular artery and external jugular vein in a patient presenting with ipsilateral pulsatile tinnitus.2A 58‐year‐old lady was referred by her General Practitioner to the Otolaryngology clinic with an 18‐month history of pulsatile tinnitus. This was associated with an enlarging swelling posterior to her right ear. There was no history of trauma, surgery, or percutaneous procedures to her neck, and she was otherwise medically well (Figure On examination, there was a soft, compressible, pulsatile swelling overlying the right mastoid process that pulsated in synchronicity with her heartbeat. On auscultation, a bruit was audible.Contrast CT displayed evidence of congestion of the posterior auricular division of the right external carotid artery with a large abnormal vascular channel communicating with the external jugular vein. The channel measured approximately 20 × 21 × 13 mm and was located directly below the tip of the right mastoid (Figure The swelling was excised surgically. Intra‐operatively a large, thin‐walled vein with a small arterial supply was identified deep to the lesion. The lesion was removed in toto. Histology showed cross sections of thick‐walled arterial and thin‐walled veins consistent with a benign vascular lesion.Following surgical excision, the patient's symptoms completely resolved.3Postauricular arteriovenous fistulae are rare, with only a few cases reported in English language literature to date. Many develop as a result of trauma, spontaneous cases are more commonly associated with genetic or connective tissue diseases such as neurofibromatosis type 1, Marfan's syndrome and Ehler‐Danlos syndrome.AVFs of the head and neck have been reported to present with a pulsatile tinnitus. Clinical features can also include pulsatile mass, other audiovestibular problems, and neurological symptoms. Untreated they can result in sequelae such as rupture, emboli, and steal syndrome. Larger fistulae can precipitate cardiac failure.Pulsatile tinnitus is a symptom defined as an auditory perception that is synchronous with the patient's heartbeat. Less than 10% of patients affected by tinnitus will have pulsatile tinnitus.Causes can be classified as vascular and nonvascular, as listed in Table Most commonly, pulsatile tinnitus as a result of an AVF is due to the abnormality being located along the dura or within a dural sinus. These are referred to as dural AVF. They are also reported occurring as a carotid‐cavernous sinus fistula or a vertebrojugular AVF.The widely accepted method for radiological evaluation of AVFs is digital subtraction angiography, although CT or MR angiography and Doppler ultrasound are also useful techniques.Small, asymptomatic AVFs often do not require treatment, although some authors suggest early intervention is appropriate to prevent enlargement of the fistula and avoid any subsequent complications.There are various modalities available for managing AVFs. With the advancement of percutaneous radiologically guided procedures, options include endovascular balloon, stent, or coil embolisation. Alternatively, surgical excision can be undertaken.4Spontaneous AVFs in the head and neck are rare and a significant proportion are associated with genetic or connective tissue diseases. They classically present as a pulsatile neck mass, sometimes accompanied by associated audiovestibular and neurological signs and symptoms. Treatment options include conservative management, endovascular intervention, or surgical excision.In this case, a simple surgical procedure removed the lesion and cured the patient of her troublesome symptoms.We received no specific grant from any funding agency, commercial, or not‐for‐profit sectors, and we are not aware of any competing interests.HW: main author. SKMD: contributing author. AA: contributed images. AKR: supervised and approved all drafts. We the authors confirm that this report is an original work, and no section of this manuscript has been previously published by or is being considered for publication by other journals. We have written this manuscript collectively with contributions from all authors as listed above. The manuscript has been read and approved by all authors involved. As principal author, I, Holt Walters am willing to take responsibility for the integrity of the content of the manuscript.Approval from an ethics committee was not required in this case; however, verbal and written informed consent was obtained from the patient prior to submission for publication.


Teaching Point: Adenoma malignum is a rare, non-HPV associated subtype of mucinous adenocarcinoma of the cervix, of which we present an exceptional case that was discovered during the third trimester of pregnancy. A 35-year-old 38-weeks-pregnant woman was referred to the gynaecology department of our hospital for the diagnostic workout of excessive pre-labor watery vaginal discharge. She had no other clinical symptoms. Lab results were normal. Cervical Papanicolaou cytopathology showed a high number of neutrophils, suggesting an inflammatory etiology, without signs of malignancy. Nevertheless, at clinical examination a posterior cervical mass was palpable.Figure 1). Because of the lesion’s size and the upcoming partus, additional magnetic resonance imaging (MRI) was urgently performed. It showed a well-circumscribed mass in the posterior cervical wall . The mass was iso-intense to the uterus on T1-weighted imaging. It had a heterogenous signal intensity on T2-weighted images, with multiple T2 hyperintense foci, correlating with the cystic/mucinous lesions seen on ultrasound. A high amount of fluid was demonstrated in the superior portion of the vagina and there was a disruption of the posterior portion of the hypo-intense fibrous cervical stroma, with the mass growing into the posterior fornix of the vagina. There was no invasion of the posterior vaginal wall, the parametria or peritoneum. The mass showed slight diffusion restriction . A tru-cut biopsy of the cervical mass was performed and showed a mucinous endocervical adenocarcinoma of the minimal deviation adenocarcinoma subtype, also called adenoma malignum. After delivery (with c-section), hysterectomy, salpingo-ovariectomy and lymphadenectomy were performed.Transvaginal ultrasound confirmed the presence of a large cervical mass (maximum diameter of 5.5 cm) located predominantly on the posterior portion of the cervix. The mass had a slightly heterogenous and hyperechoic appearance, with some small cysts. Color Doppler showed some vascularity  are squamous cell carcinoma, the other 20–25% are adenocarcinomas. Adenoma malignum is a rare, non-HPV (Human Papilloma Virus) associated subtype of mucinous adenocarcinoma of the cervix, arising from the mucin-producing columnar epithelium of the endocervical glands, accounting for 3% of cervical adenocarcinomas .An important clinical finding associated with adenoma malignum, is an excessive amount of watery discharge. The lesion is often associated with mucinous tumors of the ovary and with Peutz-Jeghers syndrome, which is characterized by hyperpigmented macules on the lips and oral mucosa and benign hamartomatous polyps of the gastro-intestinal tract.Because of the deceptively benign appearance both on imaging  and on histopathology, adenoma malignum may be wrongly interpreted as a benign lesion. However, it disseminates early into the peritoneal cavity and more distal sites and has only a minor response to chemotherapy and radiation therapy. The prognosis is thus poor.


A 73-year-old man with a history of follicular lymphoma ten years ago with complete remission presented to the emergency room with a large unilateral left-leg swelling as the only symptom. Doppler ultrasonography ruled out deep vein thrombosis. Bedside point-of-care ultrasound (PoCUS) revealed left moderate hydronephrosis. A CT of the abdomen showed a bulky soft tissue mass in the region of the distal left psoas muscle. The mass was generating an extrinsic compression of the left ureter and venous system. The histological study of the lesion established the diagnosis of follicular lymphoma recurrence. The patient subsequently received immunochemotherapeutic treatment in the oncological treatment center.This case report is intended to promote awareness about a possible clinical correlation between unilateral leg swelling and hydronephrosis with a compressive intra-abdominal mass. An adequate clinical correlation and the availability of fast and accurate diagnostic methods such as bedside point-of-care ultrasound (PoCUS) are fundamental in the emergency room for the diagnosis of pathologies with an atypical presentation. This report describes an unusual clinical presentation of follicular lymphoma recurrence, which required multidisciplinary management.Follicular lymphoma is the second most common lymphoma worldwide and represents 30-35% of all non-Hodgkin lymphomas and up to 70% of "low grade" lymphomas . PatientThe highest incidence is observed in adults in the sixth decade of life, with a male:female ratio of 1:1.7 . The mosClinically, most patients have an advanced-stage disease, and only 15-20% are in stages I or II at the time of diagnosis. Patients usually have a general preserved state; the development of B symptoms  is rare. Patients with follicular lymphoma typically have slightly enlarged superficial lymph nodes, which sometimes go unnoticed. In some patients, the first symptoms manifest themselves insidiously, and they are related to the slow growth of lymph nodes in deep areas, usually in the infra-diaphragmatic, retroperitoneum, mesenteric, or iliac regions. In such cases, patients may complain of nonspecific abdominal symptoms.A 73-year-old man presented to the emergency room with a massive unilateral left-leg swelling that had started two months ago. He had been treated for follicular lymphoma ten years ago with a complete course of chemotherapy, which had led to complete remission, His medical history also included laparoscopic cholecystectomy, chronic kidney disease, and parkinsonism for which he was on medication. He denied any history of trauma, fever, rash, vomiting, diarrhea, lower urinary tract symptoms, hematuria, weakness, loss of weight, or night sweats. A thorough physical exam only revealed severe swelling of the whole left lower limb, including the thigh and the leg, when compared with the right lower limb. The patient had mild abdominal distension. The rest of the general and systemic examination was within normal parameters.Investigations and diagnostic proceduresA Doppler ultrasonography was performed, which ruled out deep vein thrombosis. Laboratory tests revealed renal impairment , hypokalemia (potassium: 3.1 mmol/L), and hypochromic normocytic anemia. The liver function tests and his blood gases results were within normal limits. Bedside PoCUS revealed left kidney moderate hydronephrosis  reported hypermetabolic soft tissue mass in the left psoas region highly suspicious for disease recurrence. Also, it showed suspicious malignant lesions in the lower abdomen, mesorectal regions, left iliac bone, right nasopharyngeal soft tissue, and mediastinum. CT-guided flow cytometry on left psoas muscle lesion biopsy showed approximately 47% of T cells (thymus cells) and 13% of B cells (bone marrow cells) with a partial expression of CD10. B cells were negative for the expression of the superficial light chain. However, due to the small sample provided and its low cell count and viability, the clonality was not concluded with confidence. Therefore, these results must be correlated with histopathological findings. CT-guided mass biopsy revealed atypical lymphocytic proliferation composed of small B cells expressing CD10 and CD23. These results were highly suggestive of follicular lymphoma recurrence.TreatmentThe patient was referred to the urology department, where he underwent the placement of a double-J (DJ) catheter to relieve the obstruction and ensure the flow of urine from the kidney to the bladder. Afterward, the patient was referred to the National Center for Cancer Care and Research (NCCCR) to ensure adequate disease management and to start a suitable chemotherapy plan.Outcome and follow-upThe patient planned to have a course of six cycles of rituximab, bendamustine, and rasburicase. He received the first cycle, and then he was discharged home. He did not develop any adverse effects apart from mild nausea and vomiting. He regularly visited the out-patient department for following up. He was followed up for three months and a plain CT scan of the abdomen and pelvis was performed, which showed a significant reduction in the size of the mass.The definitive diagnosis of follicular lymphoma requires the histological examination of an adequate sample of tumor tissue . In the Although less than 10% of patients with follicular lymphoma are found to be in stages I/II at the time of diagnosis of the disease, between 30-40% of these patients can be cured by radiotherapy (RT) of the affected field ,6. That In patients in advanced stages, it is recommended to start a chemotherapy regimen. Although there are a number of chemotherapy regimens with proven efficacy, no particular regimen has been established to be superior over another in terms of the overall survival rate. It is important to note that the addition of RTX to these chemotherapeutic regimens has managed to improve the results in a statistically significant way in the form of increased rates of complete remission, duration of response, and disease-free survival ,9. In thThe response rate achieved with immunochemotherapy is very high; however, in most cases, the disease persists, and with rare exceptions, a more or less late relapse occurs. To avoid relapses, different therapeutic strategies have been developed, including maintenance treatments with interferon or RTX, consolidation with high-dose chemotherapy with autologous hematopoietic progenitor transplantation, and radioimmunotherapy. The treatment of relapse of follicular lymphoma depends on the efficacy achieved with the previous regimens, and schemes that do not have cross-resistance with the previous treatment should be used. In this sense, medications such as R-CHOP or bendamustine with or without RTX may be reasonable options. The NCCN clinical practice guidelines in oncology recommend treatment with an alternative line of chemoimmunotherapy , radioimmunotherapy (I 131-tositumomab or Y90 ibritumomab tiuxetan) or any of the regimes of second-line used in patients with diffuse large B-cell lymphoma (DLBCL) .The case we presented was an unusual case of recurrence of follicular lymphoma since the only symptom was swelling of the left leg. The availability of the bedside PoCUS was of great importance since it allowed us to discover that the patient had left hydronephrosis and left hydro-ureter.Anatomically the ureter is divided into three parts . In its iliac portion, the ureter crosses in front of the iliac vessels and the psoas muscle to enter the pelvis, where it joins the bladder. This anatomical knowledge allowed establishing a clinical correlation between the hydro-ureter, hydronephrosis, and the left leg swelling with the possible presence of an intra-abdominal compressive mass. The CT KUB confirmed the suspected diagnosis and the histopathological study of the lesion allowed to establish the diagnosis of follicular lymphoma recurrence.Several cases of patients with either unilateral hydronephrosis or leg swelling due to a space-occupying lesion that causes compression of the venous system and ureter have been reported. These include retroperitoneal fibrosis, ureteropelvic junction obstruction, bladder distension, ureteral tumors, psoas muscle hydatid cyst, and psoas abscess -17.Through this case report, we seek to emphasize the need for a thorough evaluation and the establishment of adequate clinical correlation in those patients who present with unilateral swelling of the lower extremities and hydronephrosis. Bedside PoCUS and CT are helpful to answer specific clinical questions, confirm the presence of a compressive intra-abdominal mass, and accelerate the treatment of patients.The presence of unilateral leg swelling and ipsilateral hydronephrosis increases the likelihood of the diagnosis of an intra-abdominal compressive mass suspect that compresses the ureter and venous system of the affected side. Bedside PoCUS can lead to specific clinical hypotheses and accelerate the diagnosis and treatment of patients. A previous history of follicular lymphoma should alert a high index of suspicion of possible recurrence.


An 85‐year‐old woman was admitted to a hospital with abdominal pain. Five years prior to admission, she had a history of hilar cholangiocarcinoma of pStage IIIC. Contrast‐enhanced computed tomography showed a mass between the rectum and uterus as well as bowel obstruction due to the lesion. Colonoscopy showed severe stenosis at the lower rectum and elevation of the submucosal layer with linear erosion. Rectal cancer was suspected, and pelvic recurrence of hilar cholangiocarcinoma or endometrial carcinoma infiltrating the rectum was considered as differential diagnosis. She underwent robot‐assisted low anterior resection combined with partial resection of the uterus. The immunohistopathological findings of the resected specimen favored a diagnosis of metastasis of cholangiocarcinoma, rather than primary rectal cancer or endometrial carcinoma. There were no signs of recurrence after 10 months of follow‐up. Hilar cholangiocarcinoma is a disease with poor prognosis. Recurrence is frequently experienced even after curative resection. Patients with recurrence are rarely candidates for re‐resection. However, better prognosis is reported for those with complete resection. Hilar cholangiocarcinoma is a disease with poor prognosis; recurrences are frequently experienced even after curative resection. However, very few reports focus on resection of the recurrence site. We herein report a unique case of rectal stenosis due to solitary pelvic recurrence of cholangiocarcinoma which was successfully resected. Hilar cholangiocarcinoma is a disease with poor prognosis. Recurrence is frequently experienced even after curative resection. Patients with recurrence are rarely candidates for reresection, but better prognosis is reported for those with complete resection. Here, we here report a unique case of an 85‐year‐old woman with rectal stenosis due to solitary pelvic recurrence of hilar cholangiocarcinoma, which was successfully resected. The patient remained free from cancer after 10 months of follow‐up.An 85‐year‐old woman was admitted to a gastroenterology hospital with abdominal pain. Five years prior to admission, she had a history of left hepatic trisegmentectomy, caudal lobectomy, extrahepatic bile duct resection, and lymphadenectomy for hilar cholangiocarcinoma of pStage IIIC  Cancer Staging Manual Eighth Editionet al.et al.Cholangiocarcinoma is a disease with poor prognosis. Surgical resection with lymph node dissection is the only curative treatment. However, only 18–42% of patients are eligible for surgical treatment at the time of diagnosis.In our case, histopathological results favor dissemination of cholangiocarcinoma, which is usually observed in terminal‐stage patients as they have unresectable multiple lesions. However, it was successfully resected owing to its solitary state. To the best of our knowledge, there are no reports for solitary pelvic dissemination of cholangiocarcinoma, and this is the first report describing a curative resection of solitary pelvic recurrence of hilar cholangiocarcinoma.The authors declare no conflicts of interest associated with this manuscript.


Extra-pulmonary tuberculosis (EPTB) arising in extra-oral region in head and neck are rare, and when swellings arise from other sites such as infraorbital region, cheek, etc, tuberculosis is not usually considered for the differential diagnosis (DD) and often the diagnosis is missed and appropriate treatment is delayed. We report a rare entity of primary tuberculosis, which presented as infraorbital swelling and our technique of performing sublabial approach to the swelling with endoscopic guided excision of the swelling and also we have review of literature of similar cases of primary tuberculosis presenting as swelling over the face over the past 5 year.Primary EPTB should be considered as DD in cases of chronic facial swelling. Tuberculosis (TB) is a chronic granulomatous disease affecting human being, which is caused by mycobacterium tuberculosis, mycobacterium bovis and other atypical mycobacterias. Primary TB affects the lungs, lymph nodes, meninges, joints, skin and other tissue of the body. When it comes to extra pulmonary tuberculosis, we often face challenge in its diagnosis as well as for its management. The incidence of primary tuberculosis of oral cavity is reported as 0.05-5%. Among thExtra oral cases of primary tuberculosis is rare and often present as fistulas, ulcers, skin lesions. To our best knowledge, we present a unique site of primary tuberculosis and a method of its management.52 year old female presented to the department of otorhinolaryngology with complain of unilateral gradually progressive swelling over the left side of the nose below the eyes since 2 months. The swelling was painless to begin with, but patient gives history of pain over the swelling since 2 weeks. There are no aggravating or relieving factors. No history of radiation of pain. No history of recent trauma. Patient also gives history of watering of left eye since 2 days. Not associated with nasal obstruction, nasal discharge. No history of visual disturbance. There was no history of significant weight loss or loss of appetite. No significant medical history , or family history.On examination she was conscious cooperative and well oriented to time place and person. Vitals were stable. A swelling measuring 1.5 x 2 cm was noticed on the lateral aspect of the nasal bridge, inferior to the infraorbital ridge. Firm in consistency, irregular surface, ill-defined margins, non-tender, mobile in horizontal and vertical direction, no local rise of temperature, no skin changes and skin was pinch able. Rest of the ear, nose, throat and neck examination were within normal limits. No palpable neck lymph nodes.On investigationBlood parameters were within normal limits except for ESR, which was 76mm/hr.HIV, HbsAg and HCV were negative.FNAC was done from the lesion which showed multiple inflammatory cells- suggestive of chronic inflammation. A plain CT scan was done which showed- soft tissue density noted adjacent to anterior wall of left maxillary sinus. The lesion is not involving the anterior wall of sinus. .Chest x-ray PA view was normal Patient was planned for excision of the lesion under ga and was taken up for surgery after anaesthetic pre-op fitness. A cosmetically better approach was planned for this case i.e endoscopic sublabial approach to the swelling. Lesion was identified, it was a well encapsulated lesion present over the inferior orbital margin extending 1cm from the medial canthi laterally to the root of the nose. Lesion was removed in toto and sent for histopathology . The histopathology showed epithelioid cells with caseation suggestive of tubercular pathology .Later the patient was subjected to Mantoux test and sputum for acid fast bacilli and was found negative for both test. Patient was started on category 1 antitubercular treatment. And patient has successfully completed 4 months with good compliance and no recurrence of swelling post-surgery.Extra pulmonary tuberculosis (EPTB) is described when the causative organism- Mycobacterium tuberculosis affects organs other than lung. It can affect any organ isolated or along with the primary foci in lung. The spectrum of EPTB can range from fatal illness when it affects the pericardium or meninges to benign lesions such as scrofula or lymphadenitis. The burden of the EPTB is 15-20% of the total tuberculosis cases. While in HIV cases it accounts for almost 40-50% of the cases. Among the estimated 2.1 million cases of TB around 16 percent that is equating to 3,36,000 cases were EPTB ,2. The diagnosis of EPTB can be difficult due to the absence of typical constitutional symptoms of TB. Microbiological tests are often inconclusive i.e FNAC and culture, because the cutaneous tuberculosis is paucibacillary (bcr). Which held true for our patient also FNAC was inconclusive and did not point towards TB. Histopathological finding are characteristic of TB but remains difficult to be differentiated from the other granulomatous diseases. In our case HPE report was suggestive of TB. MRI and CT often aid in differentiating TB from other benign lesions. In our case patient underwent CT which was suggestive of soft tissue density noted adjacent to anterior wall of left maxillary sinus. The lesion was not involving the anterior wall of maxilla.  Even with active preventive measures, tuberculosis is still a burden to the society. There has been an increase in the incidence of EPTB among individuals with AIDS and other immunocompromised conditions. Of late few cases of primary tuberculosis of cheek have been reported. Thus we should routinely screen cases of cheek swelling for tuberculosis.


Hypotropic dissociated vertical deviation (DVD) is a special form of strabismus characterized by a slow drift of the non-fixating eye when the other eye is fixating on a target. In contrast to hypertropic DVD, which is common, hypotropic DVD is exceedingly rare and seldom reported in previous literature. In this case, we report the clinical features of a rare case of a Syrian child with bilateral hypotropic DVD accompanied by manifest latent nystagmus and intermittent exotropia.A 4-year-old Syrian Arab girl presented with intermittent exotropia of both eyes since the age of 7 months, without any prior treatment. The fixation was alternating. She had manifest latent nystagmus in both eyes and anomalous head posture. She had bilateral hypotropic DVD in both eyes which only appeared when covering each eye. The patient underwent bilateral lateral rectus recession with posterior fixation and bilateral inferior oblique recession. Three months after surgery, she was orthophoric in the primary gaze position with a normal head posture. No alteration of the appearance of the hypotropic DVD was observed after the surgery.This is a rare case of hypotropic DVD showing bilateral hypotropic DVD with different characteristics from those previously reported cases . The hypotropic DVD only appeared when covering each eye, and thus there was no need for surgery. Moreover, the inferior oblique recession did not seem to negatively affect the appearance of the eyes. Dissociated vertical deviation (DVD) is a unique form of strabismus characterized by slow vertical drift of the non-fixating eye when the other eye is fixating on a target or when covering the eye. Hypertropic DVD is common and usually accompanies congenital esotropia and latent nystagmus –3. HypotMost previous cases reported hypotropic DVD as frequently being unilateral with an acquired etiology. Reported causes were intraocular injuries, high myopia, anisometropia, and poor best-corrected visual acuity (BCVA) . The mecIn this case, we report a Syrian child with bilateral hypotropic DVD accompanied by manifest latent nystagmus and intermittent exotropia.A 4-year-old Syrian Arab girl presented with intermittent exotropia of both eyes since the age of 7 months, without any prior treatment. She appeared to be in good health.Cyclorefraction was +1.00 +1.00 × 85° for her right eye, and +1.00 +1.00 × 65° for the left eye. The girl was not cooperative for visual acuity testing. The fixation was alternating. The exodeviation was very variable due to significant dissociated horizontal deviation (DHD) in both eyes.There was bilateral inferior oblique overaction (+2) along with bilateral superior oblique underaction (−1) and significant V-pattern. She had manifest latent nystagmus in both eyes that significantly decreased in the downgaze.She had an anomalous head posture: chin up (downgaze) to inhibit nystagmus and exotropia. Bilateral hypotropic DVD in both eyes only appeared when covering each eye  and bilateral inferior oblique recession of 10 mm.Three months after surgery, she was orthophoric in the primary gaze position with a very mild V-pattern and very mild residual right inferior oblique overaction. The patient also had a normal head posture. No alteration in the appearance of the hypotropic DVD was observed for either eye after the surgery, and it still appeared only by covering each eye (see Additional file Hypotropic DVD is characterized by a dissociated hypo-deviation of one eye that presents intermittently only while the other eye is fixating on a target.et al. were the first to describe a case in 1999, and they reported two cases; the first was associated with high myopic anisometropia, the second with a penetrating ocular injury [et al. reported the last published case in 2013, a female with unilateral esotropia, hypotropic DVD, and mild amblyopia [Kraft r injury . Kowal ar injury . Greenber injury . Rajavi mblyopia . A summaAll reported cases except one were unilateral. The only previously published bilateral case was related to an acquired neurologic injury, in contrast to the other unilateral cases. Two additional unpublished bilateral cases were previously mentioned in the literature . Our casThe most prominent feature in all cases of unilateral hypotropic DVD was a vision deficit in the hypo-deviated eye. All but two cases , 4 had sGenerally, a certain amount of difference in visual acuity between the two eyes commonly exists in cases of hypotropic DVD, although the degree of difference may be quite variable . Our patet al., which had latent nystagmus, and the authors mentioned that the etiology was controversial [Hypotropic DVD seems to have an acquired etiology in all previous cases; therefore, they did not have latent nystagmus. The exception is the case reported by Rajavi oversial , 4. Our Hypotropic DVD is similar to hypertropic DVD in various aspects of oculomotor characteristics. Similarities between these two conditions include slow vertical drift and returning to the primary gaze position of either eye, the dissociated nature of the deviation depending on the fixation status, intermittence of the deviation depending on the fusional status, and possible association with horizontal strabismus . In our In conclusion, this is a rare case of hypotropic DVD showing bilateral hypotropic DVD with intermittent exotropia, dissociated horizontal deviation, manifest latent nystagmus, and bilateral inferior oblique overaction. The hypotropic DVD only appears when covering each eye; thus, there is no need for surgery. Moreover, the inferior oblique recession does not seem to negatively affect the appearance of the eyes.Additional file 1. Strabismus examination at the presentation.Additional file 2. Strabismus examination after the surgery.


Acute appendicitis is one of the most common causes of abdominal pain at the emergency room. In rare cases, it can be caused by malignancy, even metastatic lesions from extra-abdominal neoplasia. Herein, we report a case of a 64-year-old female with a history of invasive ductal carcinoma of the breast treated by chemotherapy, surgery, radiotherapy and hormonotherapy, relapsing several years later as a bone and a pleura metastasis successfully cured by locoregional therapy and hormonal treatment. She presented with acute abdominal pain without signs of peritonitis. Abdominal computed tomodensitometry showed sign of appendicitis. Therefore, laparoscopic exploration and appendicectomy was performed. During surgery, multiple peritoneal nodules were found and harvested. Pathology showed metastatic nodules of invasive ductal breast carcinoma, including in the appendicular wall, concluding to peritoneal carcinomatosis. The postoperative course was uneventful, but the patient died 1 year later after refusing anticancer treatment. Breast cancer (BC) is the most frequently diagnosed cancer in women, representing 11.6% of all new cancer cases in 2018. Its prognosis significantly improved during the last three decades, thanks to better screening and medico-surgical treatments. However, around 10% of patients will develop metastasis, most frequently in bones, liver, lungs or brain. Metastasis to gastrointestinal tract and peritoneum are uncommon, especially to appendix for which clinical presentation and imaging can mimic appendicitis. Acute appendicitis is one of the most common causes of abdominal pain at the emergency department. Usually due to obstruction of the lumen at the appendicular basis (by stercolith or lymphoid hyperplasia), a malignant tumor is found at final pathology in <1%. We present the case of a 64-year-old female who was treated for an acute appendicitis, which eventually turned out to be a metachronous metastases from BC developed 20 years before. This case report was approved by the Institutional Review Board of our institution and was performed in accordance with the precept of the Declaration of Helsinki.A 64-year-old woman was admitted to the emergency department for hypogastric and right lower abdominal quadrant pain that appeared 15 days ago. The pain presented as transient crisis lasting about 10–20 min, without any triggering factor and without analgesic position. The patient mentioned a weight loss of 8 kg within the last 2 months.In her past medical history, she had a breast ductal carcinoma 20 years ago, treated by neoadjuvant chemotherapy, right mastectomy, adjuvant radiotherapy and hormonal therapy (tamoxifen) for 5 years. She relapsed 10 years later as a sternal metastasis, treated by radiotherapy and a 6-year treatment with exemestane and bisphosphonate. Shortly after stopping hormonal treatment, a right pleural metastatic lesion was diagnosed on computed tomodensitometry (CT), not responding to taxol, and treated by thoracoscopic talcage 4 years ago. The disease stabilized with an ongoing letrozole-based treatment.N<1), white blood cells at 15 000 μl/m3 (N<10 000) and no liver or renal function tests alteration. On abdominal CT, a dilated appendix (12 mm) was observed with wall thickening and periappendiceal fluid, suggesting acute appendicitis  and membrane positivity for E-cadherin; there was no staining for Human Epidermal Growth Factor Receptor-2 (HER-2). The proliferative activity was estimated between 5 and 10%.After refusing any anticancer treatment therapy, the patient died 1 year after appendicectomy. By retrospectively analysing imaging performed at the emergency department, we observe that the nodules of peritoneal carcinomatosis could be identifiable on CT images .Approximately 10% of patients with BC develop secondary lesions, either synchronous 20%) or metachronous (80%) after a median follow-up of 7 years 0% or met.Clinical presentation of peritoneal carcinomatosis from BC is unspecific, variable and poorly described . BecauseRegarding histological subtype, lobular carcinoma, representing 10% of BC, is more likely to metastasize to abdominal organs and peritoneum than ductal carcinoma , 7. ThisIn conclusion, acute appendicitis caused by metastasis from invasive ductal breast carcinoma is rare. Although the occurrence of peritoneal carcinomatosis in BC is low, one should be aware of this diagnosis, especially in patients with a history of mammary cancer even after a long period of recurrence. This can be manifested by any kind of abdominal symptoms, including acute appendicitis, and abdominal imaging is mandatory and specifically analysed with the clinical neoplastic context.


Small bowel obstruction during pregnancy is rare and can be detrimental to both mother and fetus. In most cases, management eventually involves surgical intervention. Little is known regarding optimal mode of delivery in those with bowel obstruction during pregnancy. We present a case of vaginal delivery during acute small bowel obstruction as well as a review of recent literature regarding mode of delivery in the setting of bowel obstruction. Our case and literature review demonstrates that in pregnancies complicated by small bowel obstruction, successful vaginal delivery can be achieved in those with stable maternal-fetal status. Small bowel obstruction during pregnancy is rare –6. It isA 20-year-old G1P0 at 29 5/7 weeks presented with abdominal pain, lower back pain, dysuria, and persistent emesis. The patient had been seen two days prior and diagnosed with gastroenteritis. On exam, the patient was noted to be afebrile, tachycardic to 120 beats/minute, and had bilateral costovertebral angle tenderness. Laboratory findings were notable for a leukocytosis of 21 (K/CMM). The patient was diagnosed with pyelonephritis and admitted for intravenous antibiotic administration (ceftriaxone). On hospital day 2, the patient's tachycardia persisted and her pain migrated to the right lower quadrant. A renal ultrasound was negative, and a pelvic magnetic resonance imaging (MRI) demonstrated acute appendicitis . GeneralPostoperatively the patient received a course of piperacillin-tazobactam and metronidazole. The patient also experienced delayed return of bowel function and persistent nausea and emesis. Computed tomography (CT) obtained for evaluation on postoperative day (POD) 6 confirmed a high-grade bowel obstruction. She was initially managed conservatively with nothing by mouth (NPO), aggressive intravenous hydration, and electrolyte repletion. However, on POD 7, the patient reported right upper quadrant (RUQ) pain and was noted to have a transaminitis with an ALT 609 (U/L) and an AST of 436 (U/L). A RUQ ultrasound noted cholelithiasis and biliary sludge. On hospital day 9 (POD 8), the patient had worsening transaminitis and was scheduled for a laparoscopic cholecystectomy. Laparoscopic findings were notable for adhesions and dilated, friable loops of bowel consistent with large bowel obstruction. Therefore, the case was converted to a laparotomy through a supraumbilical midline vertical incision. The bowel was decompressed via tube decompression, and adhesions were lysed. Pathology confirmed acute and chronic cholecystitis. Following her second surgery, the patient had a delayed return of bowel function but was subsequently discharged home on hospital day 18 (POD 16 and 7).She represented to the hospital at 35 4/7 weeks with diffuse abdominal pain and was found to have a partial small bowel obstruction. After consultation with general surgery, the patient was managed conservatively with NPO status, intravenous hydration, and electrolyte repletion. She had a return of bowel function and was discharged home on hospital day 2. One week later, at 36 4/7 weeks, the patient represented with abdominal pain, nausea and emesis, and lack of a bowel movement for several days. She was again diagnosed with a small bowel obstruction confirmed on CT . Given tPubMed, Google Scholar, Medline Plus, and Cochrane Review were searched for the timeframe of January 2010 to July 2020. One reviewer screened and extracted data from eligible publications. The keywords and phrases “bowel obstruction in pregnancy” or “bowel obstruction during pregnancy” or “bowel obstruction” or “bowel obstruction” or “pregnancy” were utilized. Included publications were case reports, case series, and reviews with a case presentation component. The exclusion criteria were as follows: non-English language, articles pertaining to nonpregnant patients, or publications related to pregnant patients without bowel obstruction. Data extracted included the following: year of publication, characterization of bowel obstruction at delivery (acute versus resolved), etiology of bowel obstruction, method of bowel obstruction management, gestational age at time of delivery, indication for delivery, and mode of delivery.In our review, there was a total of 54 cases of small bowel obstruction during pregnancy from a total of 32 sources during the included timeframe Tables  and 2. EIn reviewed cases of bowel obstruction during pregnancy with specified gestational age at delivery, the majority were delivered in the third trimester (92.0% or 23/25). Only 8.0% (2/25) were delivered in the second trimester. None had delivery in the first trimester. Those delivered during an acute bowel obstruction were more likely to be delivered premature. 91.7% (11/12) of those with specified gestational age at delivery were delivered premature as compared to those delivered following resolution of bowel obstruction (7.7% or 1/13). The primary etiologies of bowel obstruction were surgical adhesions (38.4% or 10/26) or volvulus (23.0% or 6/26). Forty percent (4/10) of those with surgical adhesions had a vaginal delivery as compared to 33.3% (2/6) of those with volvulus.Small bowel obstruction in pregnancy is rare –6. It ocThe management of bowel obstruction during pregnancy is dependent upon several factors including etiology, clinical presentation, maternal-fetal status, and gestational age. Conservative therapy comprising bowel rest, fluid resuscitation, and electrolyte repletion is often the preferred initial approach to care , 9, 14. A review of literature from 2010 to 2020  of those with surgical adhesions had a vaginal delivery as compared to 33.3% (2/6) of those with volvulus. Likewise, as with our patient, those delivered during acute bowel obstruction were more likely to be delivered premature. Of those with specified gestational age at delivery, 91.7% (11/12) of those with acute bowel obstruction were delivered premature as compared to 7.7% (1/13) following resolution of bowel obstruction. Given that the majority of those delivered remote from obstruction were term (92.3% or 12/13), there is insufficient data to determine if gestational age alone impacted mode of delivery in those with acute versus resolved bowel obstruction. Similarly, given that the majority of patients required surgical management (88.5% or 23/26), it was difficult to determine if management type impacted the mode of delivery.As in women with uncomplicated pregnancies, women with bowel obstruction could benefit from vaginal delivery as compared to cesarean delivery. The maternal benefits of vaginal delivery include avoidance of abdominal surgery, decreased risks of infection, hemorrhage, thromboembolism, and shortened recovery period .AvoidancSmall bowel obstruction in pregnancy is uncommon. There is little guidance regarding the mode of delivery in pregnancies complicated by bowel obstruction. We propose that in clinically stable patients without signs of fetal compromise and who are currently candidates for medical management with nothing by mouth (NPO), aggressive intravenous hydration, and electrolyte repletion, vaginal delivery should be the preferred delivery mode as it optimizes both maternal and fetal outcomes.