This study aimed to present the atypical clinical presentation and management of a metastatic lung cancer that had spread to an atypical location. Lung cancer is the most common cause of cancer-related mortality worldwide. The brain, liver, adrenal glands and bone are the most common sites of metastatic disease in patients with lung cancer. The reported incidence of symptomatic gastrointestinal metastases is 0.2–0.5%. Early diagnosis should be based on the observation of clinical symptoms and computed tomography (CT) imaging. In the present study, we describe the case of a 43-year-old male with a primary adenocarcinoma of the lung located in the lower right lobe. Following diagnosis, the patient underwent five lines of chemotherapy with a significant tumor reduction. Two years later, a mass located in the sigmoid colon was detected in the patient following a PET/CT scan. The clinical presentation was unusual with vomiting, headache, dyspnea and laboratory hyponatremia. A rare form of metastatic ulcerating adenocarcinoma was identified with colonoscopy, which was confirmed by immunohistochemical findings. A surgical approach was not performed due to the worsening condition of the patient. The patient demonstrated severe anemia and blood hypoxia, and one month later, the patient succumbed to disease. The metastasis may suggest an increase in tumor aggressiveness. Lung cancer is the most common cause of cancer-related mortality worldwide. Half of the patients affected by lung cancer develop metastases, occurring more frequently in the lymph nodes, liver, bone, brain and adrenal glands . GastroiMultidetector computed tomography (CT) with contrast medium is the optimum imaging procedure along with positron emission tomography (PET)/CT to detect colonic masses. The value of CT for depicting structural anatomy is widely appreciated and applied clinically to identify abnormalities in a non-invasive manner.The most frequent clinical presentations of GI are abdominal pain and hemorrhage; however, other symptoms, including fatigue and dyspnea, are possible.In the present study, we report the case of a young male who presented with weakness, dyspnea and headache prior to developing abdominal pain. These symptoms occurred following five lines of chemotherapy targeting the primary tumor. The clinical presentation was correlated with severe hyponatremia, most likely induced by the secretion of an ectopic antidiuretic hormone.The main previously published studies reporting on GI metastases from the lung tumor are also reviewed. Written informed consent was obtained from the patient.9/l), white blood cells (12.1×109 g/l), the sodium serum level was extremely low (120 mEq/l) with normal urinary and elevated D-dimer levels. The patient was hypoxemic with a resting PaO2 of 59 mmHg.A 43-year-old male with a 25-year smoking history (45 pack-years) was referred to the Cardiopulmonary Department in Sant’Andrea Hospital, Rome, Italy, in October 2009, due to a persistent cough and high temperature for several days. The parental history was positive for chronic obstructive pulmonary disease and cancer. The patient received antibiotic treatment without benefit over two weeks. Further investigations demonstrated mild anemia with a hemoglobin (Hb) concentration of 119 g/l and normal leukocyte and platelet counts. The oxy-hemoglobin saturation was also normal. A body CT scan revealed a lung mass measuring nearly 5 cm  in the lA total body multidetected CT scan additionally revealed a single brain metastasis located in the left parietal lobe with concurrent GI involvement. A FDG-PET scan was also performed demonstrating a tracer uptake with high intensity in two sites; the lung and sigmoid colon. A colonoscopy was also performed showing a colonic ulcerating lesion which bled on touch  and an eThe patient underwent brain radiotherapy and treatment with dexamethasone, followed by moisturizing therapy. Although no obstructive symptoms were evident, a surgical treatment was recommended on the colonic lesion to avoid obstruction and perforation, however; it was not performed due to worsening of the patient’s general condition. One month later, the patient succumbed to severe lung failure, dehydration and metabolic disorder.A search of the literature was conducted using Medline and Scopus databases. The first study that we examined identified 8,159 diagnosed cases of lung cancer collected between 1987 and 2008. The incidence of GI metastases in this study was 0.34%, 29 patients in absolute number. The specimens used to make the pathological findings were obtained either on surgical resection or on endoscopic biopsies  of symptomatic small bowel metastases from 4,114 patients with lung cancer referred to the author’s institution between 1995 and 2005 (The circulating tumor cells are important in the spread of neoplastic lesions to other organs , althougand 2005 . The medThe spread of tumor cells affects prognosis. The diffusion of disease by the hematic or lymphatic routes causes a worsening of clinical symptoms and survival rate . The dirIn the present study, we advance the hypothesis that the burden of disease is due to the aggressiveness of the tumor, and in addition, due to young age, the tumor cells propagate extremely fast and reach the arterial system of the colon.The patient initially presented with dyspnea at rest, nausea and neuralgia of lower leg, most likely due to compression of the femoral nerve roots and also fatigue. However, neither rectal bleeding nor obstruction was observed.An important consideration is that hyponatremia syndrome has a wide range of symptoms from nausea and vomiting to asthenia and edema of the brain, depending on the levels of sodium. In the metastatic phase, these symptoms are caused by low serum sodium levels, which form a metabolic condition in which there is not enough sodium in the body fluids outside of the cells . It is aet al(In this study, we identified that poorly differentiated adenocarcinoma was also atypical. A study by Berger et al reportedet al. When th


Dear Sir,The conjoined twins (CTs) are one of the most challenging conditions in pediatric surgery especially in developing countries.[1] In developed countries, antenatal diagnosis of CTs is possible at 12th week of gestation, however, in developing countries like Togo, CTs are often discovered at birth.[2] Some work on CTs has been done in Central and West Africa.[3-5] The problems of antenatal diagnoses, preoperative work up, optimum postoperative management, and ultimately poor survival was reported by all. Herein, we describe three cases of CTs that were managed a tour facility.Case 1Female CTs, born by cesarean section found joined at abdomen and chest. Prenatal diagnosis was not made. No obstetrical ultrasound was done as well. The father was 22 year old and the mother of 15 year age. Clinical examination noted that the twins were in bad general state with omphalothoracic attachment and an omphalocele. A computerized tomography scan performed showed sternal apposition, single liver, two hearts but common pericardium, and separate bowel loops. A surgical separation was decided and carried out four days later. Exploration revealed the presence of two separate hearts but contained in the same pericardium. Both hearts were morphologically normal without any anatomic malformation. There were also two lungs for each twin. However, the twins shared the same liver located in the omphalocele. The liver had a linear zone to imagine a longitudinal cleavage of two fused livers. We made the separation of the livers through the linear region and CTs were separated completely . Both CTs died one after other during operation.Case 2Male parasitic CTs were referred to us after 2 days of birth by cesarean section. The mother had three antenatal visits. No obstetrical ultrasound was performed. Clinical examination of the newborn showed normal upper and lower limbs, three limbs (two upper and one lower) were attached to epigastrium, and an omphalocele . Echocardiography revealed fibrous mitral valves with minimal mitral regurgitation and a dilatation of right cavities and of the pulmonary artery, pulmonary hypertension and a small posterior pericardial detachment. Twenty-four hours later, the baby died from acute respiratory disorder without any fever.Case 3CTs were born by cesarean section. Mother was of 22 year of age and the father of 26 year. No ultrasound was done during pregnancy. Clinical examination at birth revealed omphalopagus twins with single anus and a single umbilical cord . Each twin had two upper limbs. However, there were only two legs. One of the twins had a systolic murmur. They died five days later.Every aspect of management of CTs has problems in under-resourced and under-equipped centers. These problems are related to failure to have prenatal diagnosis, complications during labor and improper postnatal care. CTs are birth surprise resulting in chaos. In our cases, all pregnancies had to be converted to cesarean sections due to dystocia. Lack of anesthesiologist specialized in newborn surgery, and lack of a well-trained surgical staff are other areas that need improvement. Besides these factors associated major cardiac anomalies and fusion anatomy also determine the prognosis. Absence of preoperative diagnosis, inappropriate monitoring pre and per-surgery, and skills of team managing such cases lead to demise in all these cases.Source of Support: NilConflict of Interest: None declared


Complete or partial avulsion of common bile duct is a very rare injury following blunt abdominal trauma in children. A 7-year old boy presented to ER following blunt abdominal trauma by a moving motorcycle. X ray abdomen revealed free air under diaphragm and CT scan showed pancreatic contusion injury. At operation anterior wall of common bile duct (CBD) along with a 2mm rim of duodenal tissue on either side of anterior wall of CBD were found avulsed from the duodenum. The avulsed portion of CBD and duodenum were reanastomosed and a tube cholecystostomy performed. The patient had an uneventful recovery. CBD avulsion in children, after a blunt abdominal trauma, is an uncommon injury. This is often associated with hepatic, duodenal, gastric and pancreatic injuries . Avulsion of CBD may be complete or partial. In any case the presentation depends upon the extent of biliary peritonitis and associated injuries. Mostly the patients presented early within 2 to 4 days however delayed presentation has also been reported .The preoperative diagnosis of CBD avulsion is never recognized preoperatively. A case of partial avulsion of CBD with duodenal perforation presenting with pneumoperitoneum is being reported which were successfully managed by primary repair. A 7-year old boy was hit by a motorcycle in the abdomen. The patient was brought to our hospital, immediately after the incident, by emergency rescue service of the city. Patient was in obvious pain with pulse 130/min and respiratory rate 35/min. Patient was resuscitated. After stabilization an abdominal radiograph and ultrasound were requested. Abdominal radiograph revealed free air under diaphragm. Ultrasound of the abdomen showed a swollen pancreas with moderate free fluid in the peritoneal cavity. A CT scan of the abdomen was then performed that too delineated pancreatic injury .At operation, about a liter of blood mixed with bile was drained from the peritoneal cavity. There was a bruise in the area of second part of duodenum with small amount of bile in the vicinity. Pancreas was edematous and swollen. Duodenum was mobilized and an avulsion of the anterior wall of CBD having a rim of duodenal tissue (2mm) on either side was noted that resulted in a rent of about 1cm in the duodenum. Bile was freely coming from the ampulla of Vater . The partially avulsed CBD and duodenal rim were reanastomosed with duodenum in a single layer using interrupted extramucosal stitches in the long axis of the CBD. A tube cholecystostomy was then performed to divert the bile flow. The postoperative recovery was uneventful. A tube cholangiogram was performed after two weeks that showed free passage of contrast into the duodenum . Tube was removed and spontaneous closure of the cholecysto-cutaneous fistula occurred. Patient is doing well at a follow up of 6 months.The blunt abdominal injuries may result in significant insult to the various abdominal organs. Biliary tract injuries  are less frequently reported and occur in addition to other visceral injuries especially with liver, duodenum and pancreas. Isolated biliary tract injuries are extremely rare and limited to few case reports [1-4]. In our case the associated injuries were duodenal perforation and pancreatic contusion.Patients with biliary tract injuries usually present early with signs of peritonitis and even shock, however, delayed presentation has also been reported with abdominal pain, jaundice and other vague symptoms [4-6].The preoperative diagnosis of biliary tract injuries is not easy and in majority of reported cases it was made at operation. CBD may be avulsed, perforate or get contused following trauma. Rarely complete avulsion of ampulla of Vater is reported. Most of the CBD avulsion injuries are found at the level of pancreas, however, partial avulsion of CBD at the level of insertion into the duodenum has not been reported before. In our case the partial avulsion of CBD resulted in a tear in duodenum causing leakage of air and bile in the peritoneal cavity.For CBD avulsion injuries the operative procedures include reinsertion into the duodenum (choledochoduodenostomy), choledocho-choledochal anastomosis, ligation of distal CBD and cholecysto-duodenal anastomosis, roux-en-y choledocho-jejunostomy and portoenterostomy and so on [1]. We re-stitched the duodenal rim and the anterior wall of CBD with duodenal wall in the long axis of the CBD, extramucosally, thus sparing the lumen of CBD. Tube cholecystostomy was also done for bile diversion. Pancreatic injuries may result in pancreatitis or as a late presentation pseudcyst may develop [7]. In our case no such complication occurred. The other concern is related to narrowing of repaired part of CBD. This is less likely in our case as posterior wall of CBD was intact, however a long term follow up is planned to observe this complication. Source of Support: NilConflict of Interest: None declared


Insulinoma is a rare pancreatic endocrine tumor that is typically sporadic, solitary, and less than 2 cm in diameter. Ninety percent of all insulinomas are benign. Up to 10 percent are malignant and are usually larger in size. We report a case of an unusual, not yet described association of two diseases: a malignant pancreatic insulinoma recurred as a multiple liver metastasis 15 years after the initial complete enucleation of a primary tumor with a histomorphological fairly benign outlook, accompanied by ANCA positive crescentic glomerulonephritis. Insulinoma is the most common endocrine tumor arising from beta cells of the pancreas. It has an estimated incidence of 1–4 cases/million/year, based on population study , 3. AbouA 54-year-old woman was for the first time admitted to our hospital in 1996 for evaluation of recurrent episodes of hypoglycemia associated with neuroglycopenic symptoms. To evaluate the repeated episodes of spontaneous hypoglycemia, she underwent the prolonged fast. Ten hours after the last ingestion of food, her plasma glucose was 1.8 mmol/L, serum insulin and C-peptide were 22.8 mE/L, and 0.97 nmol/L respectively, clearly indicating endogenous hyperinsulinism. Preoperatively, a tumor mass was localized at the head of the pancreas by endoscopic ultrasound and confirmed by a selective arteriography of the arteria mesenterica superior. Surgical exploration confirmed the preoperative localization and a well demarcated, roundish tumor with a diameter of 15–18 mm was completely enucleated. Histopathological examination confirmed an islet cell adenoma, and the tumor was positive for insulin by immunostaining . Tumor cThe 69-year-old patient again experienced repeated episodes of seizure and conscious disturbance upon fasting. She was readmitted to our hospital. A fasting test again confirmed hypoglycemia and endogenous hyperinsulinism with a serum glucose values 1.6 mmol/L, serum insulin and C-peptide were 24.8 mE/L, and 1.03 nmol/L respectively. All currently available radiological imaging techniques could not confirm our suspicion for either recurrence of pancreatic insulinoma or metastatic growth. Repeated ultrasonography, MRI, and CT with contrast revealed scattered tiny lesions in the liver, as might be seen in cases of multiple hemangioma. Percutaneous needle biopsy of the liver and explorative laparotomy were refused by the patient . She wasIt is well established that it is difficult to predict the malignant nature of an insulinoma on the basis of its histological features , 8. The In our patient, the diagnosis of insulinoma was made clinically 15 years before the death by notifying characteristic Whipple's triad and a confirmed endogenous hyperinsulinism by a 72-hour supervised fast. The histomorphological study associated with initial surgery 15 years before the death of our patient suggested the diagnosis of a benign pancreatic endocrine tumor, compatible with a functioning insulin-producing adenoma. Reevaluation of the histomorphology and a recent application of immunohistochemistry have not only confirmed a pancreatic endocrine insulin producing tumor, but also enabled reclassification of the tumor into pancreatic insulinoma of uncertain malignant potential according to the criteria suggested by Solcia et al. . The preFurthermore, in our patient, an unusual, not yet described association of two diseases was established. An apparently extremely slowly growing metastasizing pancreatic insulinoma was found after 15 years of followup accompanied by ANCA positive crescentic glomerulonephritis. It may only be a coincidence of two causally unrelated diseases. However, a casual relationship between neoplastic diseases and immune complex forms of glomerulonephritis has been firmly established, and even cases of neoplastic diseases accompanied by pathogenetically undefined crescentic glomerulonephritis have occasionally been reported . Our pat


Acute appendicitis (AA) is the most frequent abdominal emergency surgery and the perforation, is mainly due to a delay in the diagnosis. The use of ultrasound (US) in Emergency Department (ED), could avoid delays in the diagnosis of this entity. When there is a perforation surgical morbidity multiplies by 15 and 50 the deaths.We present a case of AA, diagnosed at ED, through the use of US scanning used by Emergency Physicians (EP), and promoting their use.A patient with abdominal pain, with a final diagnosis of an AA assessing ultrasound, performed by EP. We used a Sonosite M Turbo, equipped with probe Convex C60 between 2 and 5 MHz.A male patient 18 years old, who attends the ED services, with abdominal pain, located all along his right side. No sign of nausea, vomiting or diarrhea, no fever or dysuria. He came in walking in the surgery, conscious and lucid, well hydrated and perfused, afebrile; abdominal tenderness presented an abdomen with voluntary defense in right hemiabdomen, no sign of peritoneal irritation. The rest of the exploration was normal. We have a slight leukocytosis of 10,900 without findings anywhere else in complementary tests. The patient continued with the same pain and the abdominal condition had not changed, so an abdominal US was performed, discovering an enlarged appendix, absence of peristalsis, not compressible, and the thickened wall.Ultrasound carried out by EP, can be a very useful tool in cases for which clinic and analytics are not clear. The sensitivity of US for the diagnosis of AA is high, vary from 80 to 94%, but is highly browser dependent and it is essential therefore, to have an appropriate training of the MU, to prevent diagnostic errors. To incorporate the US in ED decreases overall care time, since the EP is more efficient and dynamic, providing greater clinical safety and decreasing the complications.


We report the case of a parosteal osteosarcoma of the distal ulna, treated with wide resection without reconstruction. The patient developed lung metastasis and a mass in the interosseus membrane of the forearm proximally to the osteotomy. The lung mass was found to be a metastasis from parosteal osteosarcoma and the biopsy of the forearm mass revealed a myositis ossificans. The suspicion of a recurrence of parosteal osteosarcoma, already metastatic, led to a second wide resection with no reconstruction. A slice of the radial cortex was taken during this second procedure. From a histological point of view, good margins were achieved and diagnosis of myositis ossificans was confirmed. Two months later, a radius fracture occurred and a synthesis, with plate and screws, as added with poly(methyl methacrylate) (PMMA) to reconstruct the bone loss, was performed. Indication of the reconstructive technique and the complication after distal ulna resection in oncologic surgery are discussed in this paper. Parosteal osteosarcoma is the most common type of osteosarcoma originating from the cortex, accounting for 5% of all osteosarcomas . FurtherDue to the rarity of the localization, distal ulna resection and reconstructive options after oncologic surgery are still debated. The literature provides conflicting choices, with reports advocating no reconstruction after resection ,3, soft Given the lack of consensus in the literature on this rare condition, we present our clinical case in which parosteal osteosarcoma was treated without reconstruction, along with complications occurring after our surgical procedure.We report the case of a 41-year-old man who presented with a mass of one-year duration in the left (non-dominant) wrist. The mass was localized in the ulnar border, and was painful at rest (at night) and in flexion-extension and ulno-radial deviation of his wrist. X-rays detected a mass around the medial border of the distal ulna with periosteal reaction Figure . Magnetien-bloc resection of the distal ulna  with disarticulation of the ulno-carpal joint, performed by the orthopedic oncologic senior surgeon . Full oncologic evaluation identified a lung mass, smaller than 1 cm, in a chest CT that was not diagnosed as a metastasis (there was no metabolic activity in the body scan). Imaging follow-up  showed the mass was stable. The patient underwent an . Full onHe did not change his job (mild to heavy activity), nor his hours of work.en-bloc resection to remove the mass in the interosseous membrane with subsequent shortening of the ulna, leaving 5 cm of the proximal ulna. The ulnar nerve had to be removed during resection. Additionally, a lateral slice of the radius, close to the mass, was resected (less than one-fifth of the cortex). Histological examination confirmed myositis ossificans.At one-year follow-up, the patient had full range of motion, no sign of local recurrence, no pain during daily activities and no sign of instability, with only a mild clicking during pronation that did not bother him significantly. Radiographs showed no signs of instability. Fifteen months after surgery, the new forearm X-ray showed a small round mass (diameter <1cm), which was localized about 5 cm proximally from the ulnar resection site in the interosseous membrane Figure . The maset al.[No stabilization technique for the proximal stump was performed. After two months, an accidental fracture affected the radius and an osteosynthesis with plate, screws and PMMA was subsequently performed to fill the bony defect Figure , accordiet al..One year after the last surgical procedure, there was no local recurrence of the tumor or systemic or lung metastasis. The patient had complete ulnar nerve impairment, partial radial nerve deficit (only in the motor component), but the median nerve activity was normal.During flexion the patient presented a loss of ulnar flexion of 20° and dorsal subluxation of the stump, which was mildly bothering him. He changed his job, but he reported no pain during his daily activities.en-bloc resection. Inadequate excision of the tumor leads to a recurrence rate of 80% to 100%. While resection of the ulna is often relatively easy to perform, problems arise in the reconstruction of the defect.The therapy for parosteal osteosarcoma is a large Darrach’s procedure  for post traumatic and degenerative conditions is well described; however, patients undergoing oncological resection are different from the former because they are usually younger and highly demanding and reaching good margins for a longer bone resection leads to increased instability of the ulnar stump with dynamic radio-ulnar convergence. Clinically, this condition may lead to pain, weakness, loss of grip strength and dorsal subluxation of the distal ulnar stump, up to digital extensor tendon rupture and radio-carpal instability with ulnar translation of the carpus.The literature describes good results from the use of different reconstruction procedures in order to minimize complications after wide excision of the distal ulna .On the other hand, some authors suggest that in oncological resection of the distal ulna, reconstruction does not improve functional outcomes, and simple resection does not increase the complication rate caused by reconstructive techniques ,3,8. AltA complication of distal ulnar resection, which is not mentioned in the literature to the best of the authors’ knowledge, is myositis ossificans arising from the interosseous membrane. We believe that the micro instability of the distal ulnar stump would be the cause of bleeding and consequent myositis ossificans in our case. This has led to difficulties in differential diagnosis with parosteal osteosarcoma.en bloc resection, even with a histological diagnosis of a benign lesion.On radiological examination, the lesion of myositis ossificans should not surround the host bone, and shows a transparent line that indicates the complete separation from the cortex . However, the location of the myositis, the simultaneous detection of lung metastasis from the parosteal osteosarcoma and the rapid increase of the mass raised the suspicion of recurrence from the primary tumor, and justified the second The management of this complication led to a proximal ulnar resection. The lack of reconstruction in this resection entails more complications. The patient complained of a dorsal subluxation of the ulnar remnant during elbow flexion.After proximal ulna resection, the radius is the only bone which supports moment forces in movements and this probably led to a fracture without a trauma, even if the resection of the cortex was less than one-fifth of the entire diameter. We suggest, in the case of proximal ulnar resection, a preventive osteosynthesis of the radius to give a better mechanical stability to this segment and to avoid a possible fracture due to high moment forces on the bone segment.We suggest that the patient undergoes an autograft reconstruction with a vascularized fibular graft. Other biological reconstructive options could be autografts, allografts or a non-biological spacer made with Stainmann and cement to avoid gross instability. Every procedure is associated with a failure rate and complications, and the patient has to be aware of these.et al.[In upper limb reconstructive procedures, Gebert et al. suggest For longer defects, a vascularized fibula graft (VFG) displays an increased initial graft strength and a more rapid union.Although no final conclusion could be drawn from one case, we consider, with other authors , that, iPoor soft tissue coverage is clearly the only indication, according to the authors, for a non-reconstruction technique in a longer resection.Written informed consent was obtained from the patient for publication of this case report and any accompaining images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT: computed tomography; MRI: magnetic resonance imaging; PMMA: poly(methyl methacrylate); VFG: vascularized fibula graft.The authors declare that they have no competing interests.All authors contributed equally to this work.All authors read and approved the final manuscript.


The aim of the present study was to review the diagnostic techniques of careful radiological examination. A follow-up was performed 2 years following the surgery and the patient remained alive and a CT scan demonstrated no evidence of recurrence. However, the long term efficacy of this process requires continuous observations of the patient.Presacral schwannomas are a rare disease. The current case report presents a case of giant schwannoma with severe abdominal pain, constipation and dysuresia. The patient was initially diagnosed with an ovarian teratoma, which is an extremely common disease. The pain pattern and accompanying symptoms were the major factors indicating a teratoma. Abdominal computed tomography (CT) scans were the main tools of differential diagnosis, but the unsharpness of CT often disturbs diagnosis. Diagnosis of the tumor was confirmed by histopathology and immunohistochemistry, revealing a benign presacral schwannoma. The patient underwent complete resection and recovered well, albeit with a large amount of blood loss. The tumor was 25×15×10 cm Schwannoma originating from the sacral nerve is a rare and slow growing tumor, which arises most commonly in the peripheral nervous system . Althoug3 in size, located on the left ovary . The hypercellular areas presented elongated spindle cells, along with nuclear palisading forming Verocay bodies; whereas the hypocellular areas presented loosely arranged neoplastic cells with thick-walled blood vessels . The tumSchwannomas are benign neoplasms arising from the nerve sheath. Unusual locations, including the head, neck, peripheral nervous system, liver, pancreas, esophagus, stomach and peritoneum, have been previously reported –12. Schwet al(Ovarian teratomas are an extremely common type of abdominal tumor. Although fairly distinct in clinical and histological presentation, preoperative diagnosis of a schwannoma is not easy owing to a lack of distinguishing features on imaging studies, such as B-scan ultrasound or CT, between schwannomas and teratomas. MRI and CT are ideally suited to detect sacral pathology and delineate the soft tissue and bony components. The majority of benign ovarian teratomas without bony destroying present on CT scan . Nyapathet al previousPrevious studies have reported the misdiagnosis of schwannomas as psoas abscesses  and ovaret al(On the treatment side, surgical excision has been radically curative in a case of benign schwannoma and recurrence has been detected in few patients following incomplete removal. However, it must be noted that the pelvis is rich with blood vessels that favors hemorrhage during surgery. Tang et al reportedet al.In summary, the present case report described a rare giant presacral schwannoma in the pelvic cavity, with notable observations of its clinical manifestations of constipation, dysuria and severe abdominal pain. Histological observations make a definitive diagnosis, but the preoperative clinical manifestations and details of the differential diagnosis were ignored. If fine-needle aspiration biopsy of the tumor had been offered, the misdiagnosis may have been avoided. The follow-up process has been accomplished and patients have recovered. The current report analyzed the clinical and imaging features of the tumor to highlight possible diagnostic and management methods.


Acute pelvic pain in pregnancy presents diagnostic and therapeutic challenges. Standard imaging techniques need to be adapted to reduce harm to the foetus from X-rays because of their teratogenic and carcinogenic potential. Ultrasound remains the primary imaging investigation of the pregnant abdomen. Magnetic resonance imaging (MRI) has been shown to be useful in the diagnosis of gynaecological and obstetric problems during pregnancy and in the setting of acute abdomen during pregnancy. MRI overcomes some of the limitations of ultrasound, mainly the size of the gravid uterus. MRI poses theoretical risks to the foetus and care must be taken to minimise these with the avoidance of contrast agents.Teaching PointsUltrasound and MRI are the preferred investigations for acute pelvic pain during pregnancy.• Ultrasound remains the primary imaging investigation because of availability and portability.• MRI helps differentiate causes of acute pelvic pain when ultrasound is inconclusive.•  A wide variety of diseases may appear with pain during pregnancy. The causes of pelvic pain in pregnancy can be classified in gynaecological causes and non-gynaecological causes.Diagnosis of pelvic pain in pregnant women is confounded by several factors found in a normal pregnancy, such as nonspecific leukocytosis, displacement of abdominal and pelvic structures from their normal locations by the gravid uterus, a difficult abdominal examination, and nonspecific nausea and vomiting –3.Therefore a prompt and accurate diagnosis and treatment are essential for the well-being of the mother and the foetus, and imaging is commonly requested to clarify the clinical picture and expedite diagnosis.Given the established risks to the foetus from radiation exposure, ultrasound (US) and magnetic resonance imaging (MRI) are the preferred imaging investigations –6.US is a rapid, safe and readily available imaging modality that does not require the administration of intravenous contrast material for most emergency department indications, and it is advocated as a first-line test in the pregnant patients , 8.However, US suffers from limits such as operator-dependency, the altered body habitus, a small field of view and the presence of interfering overlying structures, and a negative study may delay diagnosis and therapy; in 30 % of pregnant patients with abdominal pain in whom the US study was negative, subsequent imaging yielded important additional findings, with 64 % of these additional findings requiring surgical intervention .MRI is a versatile, powerful imaging tool that has the potential to give more diagnostic information than any other technique especially in the absence of intravenous (IV) contrast.CT has contributed to rapid diagnosis and patient triage and has increased emergency department throughput . HoweverThe aim of this review is to explain the role of the different imaging techniques for the diagnosis and management of the different causes of acute pelvic pain during pregnancy.US is the primary imaging investigation in the diagnostic evaluation of the pregnant patient , 12.Both transabdominal and endovaginal techniques are commonly used to evaluate the uterus, ovaries and other pelvic structures .The disadvantages of ultrasound are its operator dependency and factors such as bowel gas, the gravid uterus and obesity, which may limit the quality of the examination .There are no documented adverse effects on the developing human foetus from diagnostic ultrasound . The US A careful risk-benefit analysis is required before performing CT in pregnancy , 17.When CT is used in pregnant patients, it is imperative to use automatic exposure control to reduce the radiation exposure. Protocols should minimise the use of multi-phase studies and should optimise settings to reduce the dose as much as possible without losing image quality. It is common practice to wrap areas adjacent to those being scanned with shielding. Indeed, this may provide a psychological benefit to the patient and her physicians .CT is the investigation of choice when there is a life-threatening situation and a rapid diagnosis is required. The great value of CT is that it can cover many organ systems and large patient volumes rapidly. CT is a primary tool in the case of hypovolemic blunt or penetrating trauma or severe sepsis when a variety of sites of injury or infection need to be evaluated .MRI provides a good overall topographic display and high intrinsic soft-tissue contrast, and also benefits from the lack of ionising radiation –21, makiMRI offers different potential advantages such as multiplanar imaging capabilities and the ability to detect and distinguish blood from other fluid collections , 22.A comprehensive multiplanar imaging protocol is used to evaluate the most common causes of abdominal pain. The field of view for the examination extends from the dome of the liver superiorly through the symphysis pubis inferiorly. The protocol includes breath-hold multiplanar T2-weighted sequences based on the half-Fourier reconstruction technique  and balanced gradient-echo sequences , axial and sagittal T1-weighted gradient-recalled echo (GRE) sequences and axial and sagittal diffusion sequences. The time required for this MR protocol is 20 min ; more rarely , it is ovarian (1 %), interstitial (3 %), abdominal (<1 %) and cervical (<1 %). When ectopic pregnancy involves the intramural portion of the tube, the highest rate of morbidity and mortality is seen .In a woman of reproductive age with symptoms of acute pelvic pain, a serum β-human chorionic gonadotropin (β-hCG) test is usually performed. The correlation between a serum β-hCG level above a discriminatory zone of 1,000 to 2,000 mIU/ml and the absence of a gestational sac in the uterus on transvaginal sonography is highly suspicious for an ectopic pregnancy –37.Sometimes ultrasound may conclusively diagnose ectopic pregnancy if it shows an extrauterine gestational sac with a yolk sac or embryo; more frequently, ultrasound is only suggestive of an ectopic pregnancy showing the presence of an adnexal mass (the most common sonographic finding in ectopic pregnancy) and pelvic free fluid , 38, 39.In spite of this, ultrasound presents several problems for the differential diagnosis: a corpus luteum might have the same “ring of fire” that characterises the ectopic gestational sac; the finding of an echogenic mass may be due to either an ovarian mass or an ectopic pregnancy and haemoperitoneum can be caused by both ruptured ectopic pregnancy and ruptured haemorrhagic cyst .When sonography is indeterminate MRI can be used as a problem-solving technique because of its multiplanar capabilities. MRI can help to diagnose the less common nontubal forms and to differentiate between eccentric implantation in the endometrium and an interstitial ectopic pregnancy Fig. . An inteMoreover MRI can be useful in differentiating intrauterine pregnancy associated with congenital structural uterine abnormalities from an ectopic interstitial pregnancy, and it can add information about haemorrhagic ascites and haematosalpinx; finally it can characterise adnexal masses and localisation of haematoma .Placental abruption often begins with vaginal bleeding and pelvic pain. It is defined as in utero separation of the placenta from the myometrium and causes 10–25 % of prenatal deaths , 45.The three types of placental haematoma are retroplacental, subchorionic and subamniotic. Retroplacental haematomas, posterior to the placenta, represent 43 % of haematomas; subchorionic haematomas, between the chorion and the endometrium, represent approximately 57; subamniotic ones, located between the amnion and chorion, are rare –48.The US diagnostic performance for the diagnosis of abruption is low , 50; in Because of the low sensitivity of sonography in detecting small retroplacental or submembranous haematomas or the occasional absence of bleeding with placental abruption, negative sonographic findings do not rule out the presence of placental abruption .MR imaging is superior to US in the evaluation of placenta haemorrhage because it improves soft tissue contrast and has a wider field of view –56.MR diffusion-weighted imaging (DWI) is an excellent sequence for detecting intrauterine haemorrhagic lesions. Blood breakdown products cause susceptibility effects and can be accurately demonstrated with the diffusion-weighted sequence , 58.The diffusion- and T1-weighted sequences  are more accurate than the T2-weighted half-Fourier RARE  and true FISP sequences  in the detection of placental abruption , 56, 59.Subchorionic or retroplacental haemorrhage shows low T2-weighted and intermediate to high T1-weighted signal Fig. .Fig. 3A T1- and T2-weighted sequences are both required for complete tissue characterisation. By considering the signal intensity changes with special reference to the paramagnetic effects of methaemoglobin , it is pIn trauma patients who have been subjected to a CT, a systematic evaluation of the placenta excludes the placental abruption with a reported sensitivity of 100 %; however, the specificity is significantly improved with knowledge of the normal placenta and decreases greatly without special training .Placental abruptions were characterised by large, contiguous and retroplacental and/or full-thickness areas of low enhancement that form acute angles with myometrium .Abruptions involving >50 % of the placental surface are frequently associated with foetal demise .Placental adhesive disorders (PAD) include placenta accreta, placenta increta and placenta percreta and are caused by a defect of the decidua basalis that allows the invasion of chorionic villi into the myometrium , 62. PlaPelvic US is the most commonly used imaging modality for the diagnosis of PAD –66. SonoMR findings of more severe disease include dark placental bands on T2-weighted images, with loss of normal low-signal intensity myometrium, disorganised architecture of the adjacent placenta, a focal exophytic mass and, in case of invasion involving the bladder, thinning of the uterine serosal-bladder interface, focal signal in the bladder wall and extension of intermediate signal placental tissue beyond uterine margins with loss of fat planes between the uterus and pelvic organs. , 69–72 .Fig. 4CoMRI has potential benefit compared with US because it provides a larger field of view, allowing an easier evaluation of the topography of placental invasion .Many authors recommend a two-stage approach to optimising diagnostic yield, beginning with ultrasound in patients with clinical risk factors and then proceeding to MR imaging for equivocal cases especially in patients with posterior placenta and previous myomectomy , 73–75.Other authors have suggested that MR imaging can better define areas of abnormal placentation, modify levels of invasion, ultimately change surgical management and should be used routinely , 73.Uterine rupture is a rare, catastrophic event that often presents with severe abdominal pain. Predisposing factors include previous uterine surgery, including caesarean deliveries and myomectomy, and congenital uterine malformations .When uterine rupture occurs intrapartum, abdominopelvic ultrasound shows a bulky empty uterus with an anterior hypo-/anechogenic line corresponding to the uterine tear, the foetus and placenta in the abdominal cavity and increased intraperitoneal fluid , 78.MRI allows clear visualisation of the uterine wall; therefore, it helps to diagnose both ante-partum uterine rupture in patients with indeterminate ultrasound evidence, showing the tear itself  and otheAdnexal masses occur in approximately 2 % of all pregnancies . AdnexalThe most common ovarian mass encountered in pregnancy is a benign ovarian cyst . There aMost masses can be accurately assessed by ultrasound , 84. HowFunctional ovarian cysts can be distinguished from ovarian neoplasms at MR imaging because of the presence of papillary projections and nodular septa in neoplasms . The mosOvarian torsion is increased during pregnancy and complicates 1 in 800 pregnancies. Torsion can also occur in a normal ovary, usually the right one. Ovarian torsion most often occurs between 6 and 14 weeks’ gestation when uterine enlargement is most rapid , 88.The pelvic transvaginal US represents the first step in the diagnosis: initially it is possible to observe an increase in the ovarian volume, with displaced follicles on the edge. Hyperechoic areas, signs of bleeding infarction associated with hypoechoic areas and expression of interstitial oedema may be present in the ovary. In 94 % of cases, the absence of venous flow has an elevated value predicative of ovarian torsion; the opinion on the role of pulsed Doppler or colour Doppler is discordant; although in the presence of an enlarged ovary, oedematous and painful, the absence of flow is highly suggestive of adnexal torsions .When US diagnosis is difficult, MRI can be used. MRI findings include an oedematous and thick vascular pedicle with haemorrhagic signal intensities within the ovary .It is recommended to perform a T1- and fat-suppressed T1-weighted sequence to detect haemorrhage . ContrasMR imaging features of ovarian torsion include an enlarged ovary and a thickened, twisted fallopian tube . On T1-wThe oedema, determined by the impeded venous outflow, which results in the increase of the ovarian dimensions, is manifested by an increased signal in the T2-weighted sequence.Sagittal MR imaging may be helpful in detecting a thickened tube, which appears as a tubular protrusion on the twisted side .Although it is preferable to use US and MR in the diagnosis of ovarian torsion, it can be necessary to do a CT under emergency conditions, for example, in the presence of a massive haemoperitoneum.Fibroids (leiomyoma) are the most common pelvic tumours affecting females in the fertile age group. One in 500 pregnant women experience acute abdominal pain with uterine tenderness and possibly low-grade fever owing to leiomyoma-related complications, mostly the result of haemorrhagic infarction , 94.Approximately half of all leiomyomas grow during pregnancy, mainly in the first trimester because of rising oestrogen levels . Abdomin“Red degeneration” is the most common type of degeneration during pregnancy and occurs when a leiomyoma outgrows its blood supply with resulting haemorrhage. Such leiomyomas can appear on ultrasound as circumscribed masses with cystic spaces or heterogeneous.Ultrasound features in acute haemorrhagic infarction (red degeneration) include heterogeneous or hyperechoic lesions. Later, leiomyomas may have anechoic components resulting from cystic necrosis, which allows confirmation of the diagnosis , 97.MRI can be helpful in making the diagnosis.Leiomyoma undergoing haemorrhagic degeneration during pregnancy typically exhibit diffuse or peripheral high signal intensity on T1-weighted imaging and variable signal intensity on T2-weighted imaging .The hyperintense rim on T1-weighted imaging may correspond to obstructed veins at the periphery of the mass.Kidney stones (nephrolithiasis) are not very common during pregnancy. The incidence of the symptomatic cases is estimated to be up to 1 in 2,000 pregnancies –103, andNephrolithiasis typically manifests in the second or third trimester with equal involvement of the right and left sides , 82.In pregnancy anatomical changes include dilatation of the renal calyces, pelvis and ureters due to the compression of the pregnant uterus and the effect of progesterone on the ureteral smooth muscle . The phyUltrasonography (US) is usually the primary imaging modality for evaluation of hydronephrosis and urolithiasis during pregnancy.Ultrasound is the first imaging test for suspected urolithiasis in pregnancy, despite its substantial limitations and a reported sensitivity as low as 34 % , 109.False negatives are rare and due to obstruction without dilatation, but false positives are common because of the dilatation of the collecting system that occurs physiologically in pregnancy.Ultrasound can identify stones within the renal pelvis but direct demonstration of ureteral calculi is difficult owing to the gravid uterus. Stones at the ureterovesical junction may be detected using transvaginal ultrasound. Doppler techniques have been evaluated as an adjunct , 110.Colour Doppler may show the presence of the twinkling artefact at the level of the stone even at sites where differentiation of the hyperechoic stone from surrounding hyperechoic tissues may be difficult . CompariColour Doppler can also be used to detect the passage of urine at the ureterovesical junction: the so-called ureteral jet. In the nonpregnant abdomen, absence of this sign on the symptomatic side has a very high sensitivity and specificity for obstruction .However, its diagnostic value is hampered as ureteral jets may be absent in 15 % of asymptomatic pregnant women.Possible false-positive results can be decreased by imaging patients in the contralateral decubitus position; this manoeuvre reduces the degree of physiological dilatation.Additional imaging by MR, noncontrast low-dose CT or intravenous (IV) pyelogram may be required if US is negative.MR urography should be considered as a second-line test when use of US fails to establish a diagnosis and when there are continued symptoms despite conservative management .MR imaging has high sensitivity for detection of urinary tract dilatation and identification of the site of obstruction.Although MRI does not visualise ureteral calculi, many salient features may suggest the presence of obstructing calculi. Stones appear as signal voids overlying the high signal of urine within a dilated ureter .The presence of a standing column of urine below the level of the pelvic brim, in addition to proximal ureteral dilation, is suggestive of an obstructing distal ureteral calculus (“double kink sign”) . Other MMRI is helpful in demonstrating complications such as pyelonephritis that are visualised as an enlarged oedematous kidney . Areas oIn unresolved cases, CT remains a reliable technique for depicting obstructing urinary tract calculi in pregnant women.The average estimated foetal dose, using a low-dose CT technique, was 7 mGy, i.e. below the 50-mGy limit above which there is a statistically higher risk of teratogenesis , 116.Appendicitis occurs in about 1 in 1,500 pregnancies and is a difficult diagnosis in pregnancy owing to variable appendiceal position and difficulty with clinical examination of the gravid abdomen , 118.Anatomic and physiologic changes that may disguise and delay the diagnosis of acute appendicitis in pregnant women include a cephalad displacement of the appendix from the right lower quadrant by the enlarged uterus, an increased leukocyte count and a physiologic increase in maternal blood volume that diminishes the ability to recognise tachycardia or hypotension.Ultrasound is the technique of choice for investigating suspected appendicitis, using the same parameter set for non-pregnant patients, including visualisation of a blind-ending, dilated (>6–7 mm in diameter) aperistaltic and noncompressible tubular structure arising from the caecum , 120.Therefore, if the result of the US is negative or doubtful, without an alternative diagnosis, other imaging techniques are necessary to diagnose or exclude appendicitis.MR is the method to perform in cases in which the MR scan is collocated in the ED or is however available in a short time.In suspected appendicitis in pregnancy, intravenous gadolinium is not used.MR imaging features of a normal appendix include a diameter less than 6 mm, an appendiceal wall thickness less than 2 mm, low luminal signal intensity on T1- and T2-weighted images, and no periappendiceal fat stranding or fluid .MR imaging features of appendicitis include an appendiceal diameter greater than 7 mm, an appendiceal wall thickness greater than 2 mm, appendicoliths and surrounding hyperechoic inflamed fat or hypoechoic fluid on T2-weighted images  Fig. 9)9).Fig. 9If MR imaging cannot be performed because of absolute contraindications or is not available, CT is an alternative. The risks of misdiagnosis without accurate imaging outweigh the small potential risk of ionising radiation.In the gravid patient, ultrasound is the first choice in the evaluation of bowel conditions other than appendicitis. Bowel obstruction in pregnancy is fairly uncommon . It is usually due to adhesions (60–70 %), less commonly due to volvulus (≈25 %) . In longOsteomyelitis in pregnancy is rare and represents a serious threat to the mother and especially to the good outcome of the foetus.Depending upon the location and degree of disease the patient presents with pubic or back pain, low-grade fever and altered gait, the inflammatory markers are altered in the laboratory tests .The gold standard for diagnosis is represented by tissue culture and histopathological examination; it is also possible to identify the specific pathogen responsible and set an appropriate treatment.MRI is currently considered to have the highest sensitivity and specificity of imaging modalities for detecting acute haematogenous osteomyelitis and is able to identify soft-tissue/joint complications.On MRI, an alteration of the normal marrow signal intensity is valuable; the oedema and exudates appear as defined low-signal intensity areas on the T1-weighted images and a high signal on T2-weighted and STIR images with diffusion restriction .On MRI, a sequestrum is seen as a low signal intensity structure on T1-weighted and STIR sequences, whereas the surrounding granulation tissue has intermediate to low signal intensity on T1-weighted images and high signal intensity with STIR or T2-weighted sequences  Fig. 1010.Fig. 1Determining the cause of acute pelvic pain in pregnant women can be difficult because of the multiple confounding factors found in normal pregnancy.Pelvic ultrasound is the preferred primary imaging investigation but it may be of limited value because of the altered body habitus, small field of view and presence of interfering overlying structures. MR imaging is extremely accurate in identifying both obstetric and non-obstetric causes and should be used when ultrasound findings are non-diagnostic or equivocal.In the unresolved cases, CT remains a reliable technique for depicting obstructing urinary tract calculi in pregnant women.


The association between cerebellar medulloblastoma and syringomyelia is uncommon and only found in pediatric patients. To date, adult medulloblastoma associated with syringomyelia has not been reported in the literature. Paroxysmal bradycardia is an uncommon clinical manifestation in posterior fossa tumors and likely to be vagally mediated via brainstem preganglionic cardiac motor neurons. This report introduces the diagnosis and treatment of a case of adult medulloblastoma associated with syringomyelia, which presented with paroxysmal bradycardia. However, medulloblastoma only accounts for approximately 1% of adult primary brain tumors, the majority of which are diagnosed in the third and fourth decades of life . The tumor commonly arises from the roof of the fourth ventricle, which leads to a local invasion and distant metastases through the cerebrospinal fluid (CSF) . Obstructive hydrocephalus and syringomyelia can potentially develop due to the disturbance of the CSF flow at the craniospinal level. However, there have only been isolated pediatric cases of medulloblastoma with or without hindbrain herniation in association with syringomyelia, and there are no reports on adult cases in the literatures. The clinical symptoms and signs of medulloblastoma patients are mainly headache and disturbance of cerebellar functions. The manifestation of reflex bradycardia of vagal origin associated with posterior fossa tumors, presumably via mechanical and/or ischemic stimulation of preganglionic cardiac motor neurons in the external formation of the nucleus ambiguous and dorsal motor nucleus of the vagus nerves, is an uncommon clinical finding .Medulloblastoma is an embryonal neuroepithelial tumor. It is the most common primary brain tumor in children, representing 25% of all pediatric brain tumors and around 30% to 40% of primary posterior fossa tumors This report describes a 41-year-old man who had classic medulloblastoma and an extensive syrinx in association with cerebellar medulloblastoma, and later developed paroxysmal bradycardia shortly after his hospital admission.A 41-year-old man was presented to the emergency department with progressively worsening suboccipital headache, ataxia, and diplopia. The patient had headache for 4 weeks, and it gradually increased in severity and persistence during this period. No clear precipitating and alleviating factors were identified. He also noticed that his walking gait became more unsteady and he tended to lean toward his left side. Diplopia had also been noticed a week before this presentation. No speech and language deficits, personality change, and difficulty in performing complex tasks were apparent. The patient was otherwise healthy without significant past medical or surgical histories.On examination, the patient was alert and oriented to the place, time, and persons. He was in moderate distress due to his severe suboccipital headache. His body temperature was 37°C, blood pressure was 140/80 mmHg, heart rate ranged from 60 beats to 70 beats per minute, and his respiratory rate was 18 breaths per minute. Cranial nerve examination showed diplopia at all gazes and a left horizontal nystagmus. Cerebellar disturbance was found in the left upper and lower limbs, including dysdiadochokinesia and dysmetria in a finger-to-nose test and a positive heel–shin test. A wide-based standing posture and walking gait as well as a positive tandem walking test were also noticed. Other examinations were unremarkable.A computed tomography (CT) scan of the head using an intravenous contrast revealed a solid lesion of 2.5 cm in diameter with lobulated cysts and mild contrast enhancement in the fourth ventricle (The patient was then transferred to the intensive care unit (ICU), treated with dexamethasone, and then prepared for an urgent magnetic resonance imaging (MRI) study and neurosurgical intervention. Two hours after the ICU admission, paroxysmal sinus bradycardia was found and patient heart rate oscillated between approximately 30 beats and 70 beats per minute. The occurrence of transient bradycardia made it difficult to capture blood pressure using a non-invasive blood pressure monitor. The patient complained about intensified headache during the bradycardia period.He was then transferred to an operating theater for the insertion of an external ventricular drain. Intracranial pressure was 32 cm of water, and CSF was intermittently drained to stabilize this pressure. Later, an MRI of the brain confirmed the CT findings of hydrocephalus and cerebellar tonsillar herniation (The patient’s presenting symptoms were resolved subsequently, and no postoperative focal neurological deficits were found. He was discharged a week later after undergoing outpatient radiation therapy, which involved a complete dose of craniospinal radiation with a boost on the primary tumor site. Two years after treatment, repeated magnetic resonance images showed the resolution of the syrinx and no clear radiological evidence of disease relapse (. Metastasis, young age, and residual tumor volume after resection have long been considered as poor prognostic factors in the pediatric population . Although similar factors have been studied in adults, the results of the studies are inconclusive . The main treatments of the lesion in adults are surgical resection and complete craniospinal radiotherapy along with a boost of radiation to the tumor bed. This treatment regimen yields an approximately 50% to 60% 5-year survival rate . Despite the common use of chemotherapy in pediatric patients, the role of adjunct chemotherapy in adults is still under investigation because of the different neoplastic biology, the rarity of the tumor in adults, and a paucity of prospective studies.Medulloblastoma is a primitive neuroepithelial tumor that arises from the external granular layer of the cerebellum and is considered as a Grade IV malignancy by the World Health Organization . Although posterior fossa lesions with or without cerebellar tonsillar herniation have long been postulated as a potential cause of syringomyelia, this association is not commonly observed. Syringomyelia related to medulloblastoma has only been described in isolated pediatric cases (. Many hypotheses on its pathogenesis have been proposed and the details of these hypotheses have been discussed previously. In this case, syringomyelia is likely associated with the obstruction of CSF outflow at the foramen magnum level. This association is supported by the spontaneous regression of the syrinx after the tumor resection.The pathogenesis of syringomyelia remains unclear since Charles Estienne first described it in 1546 .Paroxysmal bradycardia associated with posterior fossa tumors is also an uncommon clinical finding. It is likely to be of vagal origin via ischemic and/or mechanical stimulation of preganglionic cardiac motor neurons in the external formation of the nucleus ambiguus and dorsal motor nucleus of the vagus nerves Although adult medulloblastoma is an uncommon primary brain tumor, it should be a differential diagnosis of posterior fossa lesions. The association of the tumor with syringomyelia should also be considered in patient management. Clinicians must appreciate the important autonomic reflexes requiring a prompt clinical response.


A 52-years-old female presented with a history of a painless, progressive swelling in the left lower eyelid of one-year duration. The lesion was excised twice as a chalazion and recurred. Excisional biopsy of the mass was performed and histopathological findings were consistent with those of trichilemmal cyst. We report a rare case of trichilemmal cyst of the eyelid which was masquerading as chalazion for which the patient had undergone multiple surgeries. Wide excision was done and diagnosis was confirmed on histopathology. There was no recurrence seen till 2 months of postoperative period. Trichilemmal cyst, although rare, should be considered as differential diagnosis of recurrent chalazion. Trichilemmal cyst, also known as a pilar cyst, forms from the outer root sheath of hair follicle. They are common benign tumors most often found on the scalp . The invA 52-year-old lady presented with history of gradually progressing, painless swelling of the left lower eyelid of 1 year duration. She was diagnosed as chalazion elsewhere for which she had undergone incision and curettage twice following which the swelling recurred to the present size. There was a history of gradual increase in the size of the swelling following incision and curettage. There was no history of similar lesion anywhere else in the body. There was no significant family history. On clinical examination there was a firm, nodular mass measuring 10 × 10 × 8 mm . The masOn gross examination, it was a pentagonal full-thickness segment of the eyelid measuring 11 × 9 × 9 mm consisted of a nodular mass lesion with smooth overlying surface. Cut section revealed a unilocular cyst measuring 9 mm in diameter. Cyst was filled with yellowish homogenous solid material with focal gritty white areas .Microscopic examination showed lining keratinized stratified squamous epithelium of eyelid skin. Subepithelium showed a cyst, wall of which was composed of epithelial cells with absence of clearly visible intercellular bridges. The epithelial cells close to the cystic cavity appeared swollen filled with pale cytoplasm. The peripheral layer of cells showed distinct palisade arrangement. Cyst was filled with homogeneous, amorphous keratinous material. Patchy calcification of this keratinous material was noted. Cholesterol clefts were seen at places in the amorphous material Figures  and 4.A diagnosis of trichilemmal cyst of the eyelid was made based on histopathological findings. The postoperative period was uneventful and there was no recurrence of the swelling till 2 months following surgery.There are several types of benign and malignant lesions of the eyelids. The common benign lesions are chalazion, epidermal inclusion cysts, seborrheic keratosis, and apocrine hidrocystomas . Trichil


Pneumoperitoneum is usually associated with gastrointestinal perforation or following surgical and endoscopic procedures. We report a rare case of spontaneously perforated pyometra presenting with generalised peritonitis and pneumoperitoneum. Perforation of the uterus is also unusual and often associated with the presence of an intrauterine device, a gravid uterus or malignancy. Our case illustrates the importance of clinical knowledge of acute and neoplastic gynaecological diseases, which are not uncommonly encountered by the general surgeon. Moreover, good appreciation of pelvic anatomy and close collaboration with gynaecology colleagues is essential as operative intervention is often required. Prior to this, she had not opened her bowels or passed flatus for two days. She was a smoker of several years and had been treated for an exacerbation of chronic obstructive pulmonary disease with steroids, antibiotics and bronchodilators. Apart from hypertension and arthritis, there was no other medical or surgical history. On examination, she was acutely unwell with tachypnoea (28 respirations per minute) and mild tachycardia (98 beats per minute) but was normotensive and apyrexial. Her abdomen was distended with features of generalised peritonitis but there was no palpable mass or abdominal aortic aneurysm. Rectal examination was unremarkable. Blood tests revealed a compensated metabolic acidosis, elevated lactate at 2.5mmol/l, leucocytosis of 23,100 × 10Urgent computed tomography (CT) reported the presence of free intraperitoneal air mostly in the upper abdomen and some free fluid in the pelvis. Diverticular disease was noted throughout the sigmoid colon as well as a large cystic mass in the posterior part of the uterus. It was not possible to confirm the specific site of perforation accurately but, in the context of the presenting history, it was suggestive of either a perforated peptic ulcer or diverticulitis .Figure Following prompt resuscitation and intravenous antibiotics, a laparotomy was performed, which confirmed the presence of free air and pus as well as an inflamed sigmoid colon and dilated large bowel. Perforated diverticulitis was henceforth suspected but thorough laparotomy revealed no gastrointestinal (GI) perforation. However, closer inspection of the pelvic organs by both the colorectal and gynaecology teams confirmed the aetiology as pyometra with perforation of the anterior wall of the uterus. The posterior wall of the uterus also contained a large firm mass partially adherent to the rectum.A total abdominal hysterectomy, copious saline lavage and tube drainage was performed as a joint procedure. No colonic resection was deemed necessary. Retrospective review of the CT at the colorectal multidisciplinary team meeting reported, in addition to the previously documented findings, a fluid filled uterus with a perforation and free air in the anterior wall as well as a lesion in the posterior wall in keeping with fibroids . HistoloPost-operatively, intravenous antibiotics were continued and the patient was supported in the intensive care unit for a short period prior to stepping down to ward care and making a full recovery. Her home and social circumstances contributed to a prolonged period of convalescence and she was discharged home after 35 days.Pyometra, an accumulation of pus in the uterine cavity, has an estimated incidence of 0.01–0.5% and occurs due to inadequate drainage of endometrial secretions through the cervix.Spontaneous perforation of the uterus is also rare and has two peaks of its incidence: first, in women of child bearing age and associated with a gravid uterus or presence of an IUD; second, in elderly post-menopausal women and associated with pyometra.Abdominal pain, vomiting and fever predominate as the presenting symptoms in spontaneously perforated pyometra while gynaecological symptoms such as vaginal bleeding or discharge occur in less than 10%.Other ‘non-surgical’ causes of pneumoperitoneum are by and large iatrogenic and can be managed conservatively. Free intraperitoneal air is seen commonly following open or laparoscopic surgery, peritoneal dialysis and its complications, percutaneous endoscopic gastrostomy tube placement,and spontaneous bacterial peritonitis.Escherichia coli and Bacteroides fragilis are the most commonly associated organisms.In our case there are two possible explanations for the pneumoperitoneum. First, the presence of free intraperitoneal air may be due to gas forming organisms. Previous reviews report that Pre-operative diagnosis of spontaneously perforated pyometra is difficult but the initial management remains the same as for generalised peritonitis or GI perforation: prompt resuscitation, antibiotics and radiological investigation. While CT is often indicated in such circumstances, this case demonstrates that accurate radiological diagnosis of spontaneously perforated pyometra can still be difficult, especially when imaging is reviewed in the acute setting and often not by a specialist abdominopelvic radiologist. Given the absence of gynaecological symptoms in most cases, diagnosis is frequently not possible until laparotomy is performed.Total abdominal hysterectomy, with or without bilateral salpingo-oophorectomy, and copious peritoneal lavage is the definitive surgical treatment. Colonic resection may also be necessary in cases of colouterine fistulation or invasive malignancy. Mortality from spontaneously perforated pyometra exceeds 40% and, again, highlights the importance of multidisciplinary involvement in treating sepsis.This case illustrates several lessons for the general surgeon, who is likely to be referred patients with pneumoperitoneum. Although an uncommon finding, spontaneously perforated pyometra should feature as part of the differential diagnoses for elderly post-menopausal women presenting with an acute abdomen and pneumoperitoneum. An appreciation of acute and neoplastic gynaecological disease is essential as many patients with gynaecological pathologies may present with signs and symptoms mimicking those of GI origin. Most patients with spontaneously perforated pyometra will require surgery and so a good appreciation of the pelvic anatomy and close collaboration with gynaecology colleagues is essential. Meanwhile, meticulous clinical judgement is required in discerning which patients may benefit from conservative management.


Pilomatrixoma, also known as pilomatricoma, is a benign tumor that originates from the matrix of the hair root. It usually presents as a single, slow-growing subcutaneous or intradermal firm nodule with a general size of less than 3 centimeters (cm) in diameter. However, giant pilomatrixomas (more than 5 cm) have been reported infrequently. It is more common in females and usually presents during the first two decades of life (60%) as an asymptomatic, mobile, hard, elastic mass. Most of the cases are benign and affect the face. The authors report a rare case of a giant pilomatricoma of the cheek and discuss the surgical management of these lesions, histopathological findings, and review of the literature. Pilomatrixoma, also known as pilomatricoma or calcifying epithelioma of Malherbe, was first described in 1880 by Malherbe and Chenantais . pilomatA 28-year-old male was referred to the department of oral and maxillofacial surgery for evaluation and management of a left facial mass. He had no other medical problems and no known food or drug allergies. At the age of 15 years, he noticed a mass on his left cheek eminence, which was excised and was told that it was a sebaceous cyst. Three years later, he had a local recurrence of the facial mass that was surgically excised again showing the same pathology. A third recurrence in the same area occurred 4 years later and was excised with the overlying skin. However, at this time the pathology specimen proved to be pilomatrixoma. The mass recurred again few years later and has been growing slowly over the past 3 years prior to presentation. Clinical examination of the face showed a firm, nontender mass infiltrating the overlying skin of the left buccal subunit measuring about 5 × 3 cm. The overlaying skin had bluish discoloration . There wAnother incisional biopsy was done under local anesthesia, which confirmed the diagnosis and ruled out malignant transformation. A contrast enhanced magnetic resonance imaging (MRI) study showed a heterogeneously enhancing mass in the subcutaneous tissues overlying the left platysma muscle at the level of the mandible . The adjPilomatrixomas appear as well-demarcated, lobulated lesions situated in the dermis or subcutaneous tissue. The tumor is composed of ghost cells, basaloid cells, and giant cell, in addition to keratin debris and intracellular and stromal calcifications  5]. Unc. Unc5]. Pilomatrixoma is an unusual neoplasm of hair germ matrix origin. Head and neck pilomatrixoma represent 50% of the reported cases with the cervical, frontal, temporal, eyelids, and preauricular regions being the most frequent locations . A femalPilomatrixoma usually presents as an asymptomatic nodular single mass. The skin overlying the lesion is usually normal or may have reddish or bluish discoloration. These lesions are usually well circumscribed, spherical, or ovoid, and sometimes encapsulated. The behavior of pilomatrix carcinoma resembles that of basal cell carcinoma, but with the potential for metastasis. According to Bremnes et al., only 55 cases of pilomatrix carcinoma have been reported in the literature . Rare caThe diagnosis is usually established based on an incisional biopsy. However, fine needle aspiration cytology (FNAC) has been described as a preoperative diagnostic tool, but the results can be misleading and, at times, can lead to the erroneous diagnosis of a malignant neoplasm . These tIn summary, pilomatrixoma is a benign skin neoplasm that usually presents as a single, slow-growing subcutaneous or intradermal nodule. It is usually less than 3 cm and commonly affects the face. Giant pilomatrixoma (>5 cm), as in the presented case, is unusual. Malignant transformation has been reported but it is very rare. The diagnosis is established based on an incisional biopsy with questionable value of FNAC. The treatment of choice is surgical excision with a clear margin with every effort to preserve the branches of the facial nerve. Recurrence with adequate treatment is low.


A 49-year-old man was admitted to our hospital with a 1-month history of dysphagia. An upper endoscopy revealed a lower esophageal submucosal tumor. Immunohistochemical staining of the biopsy specimen revealed KIT positivity. Thus, the tumor was diagnosed as a gastrointestinal stromal tumor (GIST). After 6 months of imatinib treatment, the tumor decreased from 92 mm × 55 mm × 80 mm to 65 mm × 35 mm × 55 mm in diameter, and surgery was performed. The tumor was completely resected without rupture, by partial esophagogastric resection through a thoracotomy incision, using an abdominal laparoscopic approach. Immunohistochemical staining revealed that the tumor was negative for c-kit but positive for CD34. Genetic examination showed that the tumor had a mutation in exon 11. The patient experienced minor leakage but recovered conservatively. Adjuvant imatinib was initiated 64 days after surgery. We report this rare case to show the potential of preoperative imatinib treatment in patients with large esophageal GISTs, to achieve complete resection without rupture. Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the gastrointestinal tract, commonly found in the stomach 60% to 70%) and small intestine 20% to 30%) ,2. Surge0% to 30%0% to 70%A 49-year-old man was admitted to our hospital with a 1-month history of dysphagia. He did not have any history of illness or any significant family history. Physical examination revealed no abnormalities. Standard laboratory test results on serum and urine showed no significant findings. Tumor markers such as carcinoembryonic antigen, carbohydrate antigenic determinant 19-9 and squamous cell carcinoma antigen were also within the reference limits. An upper endoscopy revealed a submucosal tumor with a narrowed lumen in the lower esophagus Figure A, at theThe patient underwent surgery after the chemotherapy. The surgical procedure was a partial esophagogastric resection through a thoracotomy incision, using an abdominal laparoscopic approach. A lymphadenectomy was not performed. On gross examination, the resected tumor was soft and had shrunk to 65 mm × 35 mm × 45 mm in diameter  was initiated at 64 days after the surgery. There has been no recurrence for 12 months post-surgery.Complete surgical resection is the standard treatment for localized GISTs; however, 40% to 90% of curative resection patients experience recurrence . EsophagThe biological potential of stomach or small intestinal GISTs is related to their size and mitotic activity, which may also be true of esophageal GISTs. The prognosis is commonly stratified according to the Joensuu risk criteria  and accuAlthough the benefit of imatinib for malignant or high-risk GISTs is beyond doubt, the clinical outcome of neoadjuvant treatment has not yet been established. In our case, we were able to a perform complete resection of the GIST owing to the decreased tumor size after the treatment with imatinib. The tumor was diagnosed to be of intermediate risk according to Fletcher’s classification . We usedIn summary, we reported a case of a large esophageal GIST that was successfully resected after imatinib treatment. Although the effects of neoadjuvant imatinib therapy on overall survival are not yet clear, long-term imatinib administration has the potential to promote curative surgery for some patients with large GISTs.We treated a case of a large esophageal GIST that was successfully resected after neoadjuvant imatinib treatment. When an esophageal GIST is a certain size, located in the narrow mediastinal space and is difficult to dissect, neoadjuvant imatinib treatment might be one of the options for a minimally invasive surgical resection without rupture.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT: computed tomography; GIST: gastrointestinal stromal tumor; H & E: hematoxylin and eosin; OS: overall survival; PET: positron emission tomography; SUV max: maximum standardized uptake value.The authors declare that they have no competing interests.SY and KT wrote the manuscript. SY, KT, TS and NT performed surgery. KA carried out the pathological examination. HO was involved in the final editing. All authors approved the final manuscript.


DFSP is a locally invasive, slow-growing tumor of the subcutaneous tissue that rarely metastasizes but recurs frequently after surgical excision. We report herein a case of highly recurrent, locally invasive DFSP that failed both postoperative radiation therapy and complete trial of Imatinib, but was successfully treated with Sorafenib, which showed unprecedented response. Dermatofibrosarcoma Protuberans (DFSP) is a locally invasive and slow-growing tumor of the subcutaneous tissue. It rarely metastasizes. It was first described in 1924 as a progressive and recurrent dermatofibroma [DFSPs rarely progress to a high-grade fibrosarcomatous component . One to According to the NCCN Clinical Practice Guidelines in Oncology, The gold standards treatment is complete surgical excision with appropriate reconstruction . ImatiniWhen resection is limited or incomplete, or margins are positive recurrence rate is high -20. In tWe report hereafter a case of highly recurrent, locally invasive DFSP that failed both postoperative radiation therapy and treatment with Imatinib at 400 mg initially that was then increased to 800 mg. The patient received Sorafenib off label and showed an unprecedented response for his disease.A 36 year-old gentleman presented with a left shoulder skin lesion that was initially totally excised. Histopathology reported Dermatofibrosarcoma Protuberans (DFSP). He relapsed sometime after this initial resection and underwent a second surgery followed by several other relapses and re-resections and 2 courses of radiation therapy and ended up having multifocal disease sites on the upper torso, the shoulder and neck. Plastic surgeons exhausted all available skin that could be spared for flaps and reconstruction. After the third relapse and the first round of radiotherapy, he received Imatinib at 400 mg daily with a positive response lasting for about 2 years. Upon progression, he was offered Imatinib 800 mg daily with non negligible side effects and no response.All pathology readings of repeated excisions were reported as DFSP except for one time, where the presence of cellular pleomorphism and the lack of CD 34 expression raised the possibility of transformation into a fibrosarcoma. Margins following his third resection were always positive.There was no FISH analysis or RT-PCR or molecular studies ordered to detect the presence of the typical chromosomal translocation t in the tumor of this patient, resulting in the chimeric gene COL1A1-PDGFB.The patient ended up with left upper extremity amputation at the level of the shoulder and was referred to us.He presented with massive and bulky soft tissue lesions on his upper torso and in the neck. A contrast enhanced CT scan also revealed large mediastinal masses and post obstructive pneumopathy on the left.He was offered to start on Sorafenib as it was made available for us on compassionate use. A dramatic response was seen after only few days of treatment Figures  and 2. TDFSP accounts for 2 to 6% of all soft tissue sarcomas ,22. It iThe tumor involves most frequently the trunk (42-72%), the proximal extremities (16%-30%), and the head and neck (10-16%) especially the scalp -28.The initial presentation of DFSP is a skin lesion described as a single, raised, red to bluish, firm cutaneous nodule or plaque with surrounding discoloration . The lesAt advanced stages, the tumor can ulcerate, bleed, and become painful, as reported in our case.Near to 90% of DFSP are considered to be tumors of low-grade malignancy . HistoloThe expression of CD34 is almost a consistent finding and it is extremely useful in differentiation of DFSP from benign fibrous histiocytoma , dermatot [Cryptogenic abnormalities are also distinguishable characteristics of DFSP since more than 90% of cases have supernumerary ring chromosomes or a unique translocation involving chromosomes 17 and 22 as in  -41. This ,28. Furt .Distant metastasis is rarely observed, with a rate of 4-6%, predominantly to the lungs ,30.DFSP can transform, especially in the recurring forms, into fibrosarcomatous DFSP (FS-DFSP), a tumor with higher invasion and malignancy potential ,4,28,43.The optimal and the mainstay treatment of DFSP, regardless of its location, is wide and deep excision with adequate tumor-free margins. The proper excision with clean margins is directly related to the risk of recurrence of the disease despite adjuvant therapy ,19,44,45The most significant prognostic factor in patients with DFSP has proved to be the extent of surgical resection. The success of the initial surgical excision has a major effect on the outcome as well. In fact, if this procedure fails and hence, the tumor recurs, it could lead to an uncontrollable local growth, as seen in our case.Due to its infiltrative nature, DFSP is characterized by a high recurrence rate varying in the literature from 10-80% . The risDFSP is considered as one of the radiosensitive tumors. Earlier studies suggested that additional postoperative RT reduces the risk of local recurrence in patients with questionable or positive surgical margins ,47. WhenAs seen in the present case, locally recurrent DFSP can be devastating. Salvage by further resection increases the risk of functional deficits and metastatic disease.Since the recent identification of the significance of PDGFR activation in the DFSP pathogenesis, the effectiveness of targeted chemotherapy by inhibition of the PDGFR protein-tyrosine kinase has been evaluated. Imatinib, a small adenosine triphosphate analog is a selective PDGFR tyrosine kinase-inhibitor. It was approved for the treatment of DFSP at a dose of 800 mg daily. Such dose is easily reached orally, with non negligible side effects. Some clinical reports showed Imatinib induced regression in patients with recurrent or metastatic DFSP -17.However, response was not consistent in all cases as described in our patient.To date, no other targeted therapy for DFSP has been reported.We report the first case of recurrent and extensive DFSP successfully treated with Sorafenib after failure of postoperative radiation therapy and refractory to treatment with 800 mg of Imatinib.Sorafenib is a small molecule B-raf and vascular endothelial growth factor (VEGF) receptor inhibitor. It has shown great value in the treatment of angiosarcomas  Maki et Since it has been reported to have an important role in the treatment of some sarcomas, we elected Sorafenib as a salvage option for our patient. The response was remarkable. The tumor almost totally regressed and the patient improved clinically. This case suggests that Sorafenib could be an important targeted therapy for DFSP especially in case of recurrence or metastasis.Invasive DSFP could be uncontrollable and challenging to cure. We present a case of recurrent and infiltrative DSFP that failed all conventional therapeutic options. Sorafenib was administered as final resort with impressive results.This is to our knowledge the only reported case of DFSP treated with Sorafenib after failure of Imatinib.Sorafenib could represent a therapeutic alternative in such cases of DFSP.Written informed consent was obtained from the patient for publication of this report and any accompanying images.DFSP: Dermatofibrosarcoma protuberans; NCCN: National comprehensive cancer network; FISH: Fluorescence in situ hybridization; PDGFR: Platelet-derived growth factor receptor.The authors declare that they have no competing interests.FGK established the conception, the design, and the interpretation of data. After finalizing the draft, he approved of the version to be published. VFK has made substantial contributions to acquisition, analysis, and interpretation of data. He also was involved in drafting the manuscript and revising it critically for important intellectual content. ANS contributed in data analysis and interpretation, and was involved in revising the critical aspects of the manuscript. All authors read and approved the final manuscript.No external funding, apart from the support of the authors' institution, was available for this study.


Retaining of gauzes and surgical sponges in the abdomen is one of the most frequent medical errors usually manifesting as abscess or abdominocutaneus fistulas with no definite symptoms during lifetime. Here, we introduce a 35 year old woman with symptoms and signs of partial bowel obstruction and enterocutaneous fistulas caused by migration of retained gauze from abdominal cavity to terminal ileum, 9 months after cesarean section. This is called “Textiloma”. There are several reports of gossypiboma worldwide but migration of retained gauze into intestine causing an enterocutaneous fistula is rare. Textiloma , gossypiboma  and gauzoma  are the historical terms referred to pseudo-tumor formation and inflammatory reaction caused by a foreign body or retained non absorbable cotton matrix left behind mistakenly in patient’s body. They usually caused by abdominal and gynaecological surgeries. Despite of being rare, gossypiboma should be considered as differential diagnoses of any mechanical obstruction in patient’s underwent abdominal surgery.111There are several reports of gossypiboma worldwide but migration of retained gauze into intestine causing an enterocutaneous fistula is rare. In this report, we introduce a 35 year old woman with bowel obstruction due to migration of retained gauze into ileum.The patient was a 35 year old, G2 L2 A0 female who had discharged from cuteness fistula, frequent abdominal pains 5 months after cesarean section of her second child with Pfannenstiel incision. She was hospitalized with chief complain of anorexia, low grade fever, cutaneus fecal discharges and symptoms of partial bowel obstruction. Patient’s hemodynamic was stable. In her abdominal examination, she had periumblical tenderness but rebound tenderness and mass were not detected. There was a periumblical fistula with fecal discharges. Results of rectal and vaginal exam were normal. She had leukocytosis in CBC diff but other lab test results were normal. She had received complete bowel rest, parenteral nutritional support and antibiotics. Plain x-ray of abdomen showed dilated loops of small bowel with air- fluid levels and opacity in terminal ileum. In fistulography, there were evidences of fistula between small intestine and skin with unusual gas pattern in bowels and retained gauze in terminal ileum . FindingDespite all considerations during operation, retained gauzes are still one of the major problems. Textiloma or gossypiboma usually occurs in one out of 100 to 3000 of all surgical investigations and one out of 1000-15000 intra abdominal operations especially with busy surgical fields or emergencies, unplanned changes in procedures and high body mass index.116They can cause several complications including intestinal fistula which are important in the prognoses of the disease. Although these complications can be Fatal, they are less reported because of the legal issues.317A fistula is an unusual connection between two different surfaces. There are two types of fistula, internal  and external . About 80% of external fistulas are caused by either medical errors or diseases such as Crohn’s disease and cancers.Except for FRIENDS  most of enterocutaneous fistulas are closed spontaneously. There is usually a 10% recurrence with surgery. In patients with previous history of surgery or palpable mass in site of surgery, granuloma due to foreign body should be considered as a late manifestation.351419In cases that the sponge does not have any radiological marker, it can’t be diagnosed by radiologic screening and may mimic radiographic patterns of hematoma, neoplasm, granulomatous process, abscess formation, cystic masses, calcification and air bubbles as well. The exact modalities of granoloma due to gauze are best seen in contrast enhanced MRI.20There are only a few reports of complete migration of gossypiboma into intestine. Gencosmangulu et al reported abscess formation and severe intraluminal adhesions due to migration of laparotomy towel into midabdomen 2 years after open cholecystectomy and hernia repair in a 74 year old woman presented as small bowel obstruction. They concluded that gossypiboma should be considered as a cause for intestinal mechanical obstruction.3Silva CS et al reported complete migration of retained surgical sponge from abdominal cavity into ileum in a 24- year- old woman 4 months after caesarean section manifested with diffuse colic abdominal pain, nausea, vomiting and constipation. The patient underwent ileotomy with terminating anastomosis. No fistula or open intestinal wall was reported.4Gossypiboma should be removed as soon as diagnosed. Surgery either by laparoscopy or laparotomy is the treatment of choice especially in cases with deeply located foreign body or fistulas. In some asymptomatic cases with complete intraluminal retained gauze, follow up with endoscopy or imaging is recommended.Yet, prevention is the best treatment. Cooperation of surgical team for exact controlling of all tools and gauzes before ending the operation, intra operative radiologic screening and routine radiography of high risk patients at time of discharge are necessary to prevent further morbidities and legal issues.31423


Spontaneous bladder perforation is an uncommon event in childhood. It is usually associated with bladder augmentation. We are presenting a case of bladder rupture in an infant with neurogenic bladder without prior bladder surgery. Three days after lipomyelomeningocele excision the patient showed signs and symptoms of acute abdomen. The ultrasound exploration revealed significant amount of intraperitoneal free fluid and therefore a laparoscopic exploration was performed. A posterior bladder rupture was diagnosed and repaired laparoscopically. Currently, being 3 years old, she keeps successfully dry with clean intermittent catheterization. Neurogenic bladder voiding function can change at any time of its evolution and lead to complications. Early diagnosis of spontaneous bladder rupture is of paramount importance, so it is essential to think about it in the differential diagnosis of acute abdomen. Spontaneous bladder rupture is uncommon. In children it is usually associated with bladder augmentation , 2. The A girl was diagnosed at birth with a lumbosacral lipomyelomeningocele with voiding habits appropriate for age. Urodynamic exploration performed at 10 months showed bladder capacity of 60 millilitres with normal intravesical pressure and no significant residual urinary volume. Lipomyelomeningocele was operated, with the girl being one year old. On the third postoperative day, she developed abdominal distension and discomfort accompanied by signs of acute abdomen. An ultrasound scan detected significant amount of intraperitoneal free fluid. With the presumptive diagnosis of urinary chemical peritonitis a diagnostic laparoscopy was performed.The operation was carried out under general anesthesia with the patient in supine position. An infraumbilical incision was made down, and under direct vision a 5 mm port was placed into the peritoneal cavity. A 5 mm 30° telescope was used to visualize the operative field. Two additional 5 mm ports were placed under direct vision, one at the right lower iliac quadrant and the other in the left one. Necrosis of the posterior wall of the bladder with perforation was found. The perforation was identified, its edges resected, and the wall repaired in two layers with absorbable suture . A tube obstruction caused by urine leaking, such as children with urethral valves or imperforate hymen,those caused by bladder wall weakness, as in cases of previous bladder surgery or diverticuli,low compliance after radiotherapy or in neurogenic bladders.Spontaneous bladder rupture, defined as one that occurs in the absence of trauma or iatrogenic injury, is an extremely rare clinical entity in children –3. RevieIn our case, bladder perforation happened after removal of the urinary catheter in the immediate postoperative period after surgery of myelomeningocele. Presenting signs and symptoms depend on the age of the child and the severity of the rupture. They are nonspecific and include nausea, vomiting, fever, abdominal distension, acute abdomen, oliguria or anuria, and possible secondary sepsis. The medical record is the key to differentiate it from a urinary tract infection. Diagnosis is complex and associated with a high mortality rate –10. DefiAll patients with myelomeningocele should be treated as potential cases of neurogenic bladder. Voiding function can change at any stage of development and lead to further complications. The laparoscopy can be used in both diagnostic procedure and therapeutic procedure in peritonitis of unknown origin. Early diagnosis of spontaneous bladder rupture, though infrequent, is of paramount importance, and therefore it is essential to include it in the differential diagnosis of acute abdomen in this kind of patients.