Obturator hernia: A diagnostic challenge

INTRODUCTIONObturator hernia is an extremely rare type of hernia with relatively high mortality and morbidity. Its early diagnosis is challenging since the signs and symptoms are non specific.PRESENTATION OF CASEHere in we present a case of 70 years old women who presented with complaints of intermittent colicky abdominal pain and vomiting. Plain radiograph of abdomen showed acute dilatation of stomach. Ultrasonography showed small bowel obstruction at the mid ileal level with evidence of coiled loops of ileum in pelvis. On exploration, Right Obstructed Obturator hernia was found. The obstructed Intestine was reduced and resected and the obturator foramen was closed with simple sutures. Postoperative period was uneventful.DISCUSSIONObturator hernia is a rare pelvic hernia and poses a diagnostic challenge. Obturator hernia occurs when there is protrusion of intra-abdominal contents through the obturator foramen in the pelvis. The signs and symptoms are non specific and generally the diagnosis is made during exploration for the intestinal obstruction, one of the four cardinal features. Others are pain on the medial aspect of thigh called as Howship Rombergs sign, repeated attacks of Intestinal Obstruction and palpable mass on the medial aspect of thigh.CONCLUSIONObturator hernia is a rare but significant cause of intestinal obstruction especially in emaciated elderly woman and a diagnostic challenge for the Doctors. CT scan is valuable to establish preoperative diagnosis. Surgery either open or laproscopic, is the only treatment. The need for the awareness is stressed and CT scan can be helpful.     

The effect of length of ureteral resection on benign ureterointestinal stricture rate in ileal conduit or ileal neobladder urinary diversion following radical cystectomy

ObjectivesTo assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion.Methods and materialsWe identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis.ResultsA total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211–927). Median time to stricture formation was 235 (IQR: 134–352) and 232 days (IQR: 132–351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P = 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication≥III (hazard ratio = 2.11, 1.01–4.40) and urine leak (hazard ratio = 3.37, 1.08–10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side.ConclusionsThe etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not significantly affect stricture rate.     

Ileal perforation as an initial manifestation of systemic lupus erythematosus: A case report

Introduction and importanceLupus enteritis is uncommon in patients with SLE and usually presents with anorexia, vomiting, and abdominal pain. Intestinal perforation as an initial manifestation of SLE is rare and can have a grave prognosis if not timely diagnosed.Case historyWe report an unusual case of a 22-year-old regularly menstruating female who presented with features of perforation peritonitis as an initial manifestation of lupus enteritis. Intraoperatively, a gangrenous ileal segment with multiple perforations was present. Thus, with an intraoperative diagnosis of perforation peritonitis, a gangrenous segment of the small bowel was resected and a double-barrel jejuno-ileostomy was created.DiscussionLupus enteritis manifesting initially as bowel perforation can be an uncommon cause of acute abdomen. A plain chest X-ray can show gas under the diaphragm suggesting bowel perforation. A contrast-enhanced CT scan of the abdomen is the gold standard in diagnosing lupus enteritis with a good prognosis on steroids.ConclusionPrimary closure, resection, and anastomosis of small gut or diverting stoma are required for management of perforation. A high degree of clinical suspicion is required for early diagnosis thus preventing the grave prognosis of such an entity.     

Case report: Colon ischemia and perforation as a result of Norovirus infection

IntroductionNorovirus (NoV) gastroenteritis has been documented as the worldwide leading cause of the majority of acute cases of viral gastroenteritis. Here, we present a Case of NoV that progressed into colon perforation.Presentation of caseA 47-year-old woman was admitted via the emergency unit with diarrhoea, lower abdominal pain, vomiting and fever. The virological testing of her stool revealed a NoV infection. The abdominal CT scan showed massive pneumatosis intestinalis. Following the scan findings, the patient was admitted for a diagnostic laparotomy the same day. A side-to-side ileosigmoidostomy was performed. We performed two clinical re-evaluations of the patient, the first one took place 2 weeks after we discharged the patient and another one-year later. The patient is in perfect health.DiscussionTo the best of our knowledge and following a thorough bibliographical search, this is the first case report in Germany and the first case report of colon perforation due to NoV infection in adults in the European Union.ConclusionA NoV infection could, along with the typical symptoms, indicate a life-threatening bowel ischemia and/or necrosis.     

Emphysematous gastritis: A young diabetic's recovery

IntroductionEmphysematous gastritis (EG) is a rare and often fatal disorder involving infection of the gastric wall by gas-forming organisms.Presentation of caseWe present the case of a 25-year-old diabetic man with severe gastroparesis, who complained of vomiting and right upper quadrant pain. The surgical consultant exam in the emergency department revealed a tender but not acute abdomen. On abdominal computed tomographic imaging, there was gas throughout the wall of the stomach but no evidence of gastric perforation. The patient was treated non-operatively with antibiotics, bowel rest, serial abdominal exams, and upper endoscopy (EGD).DiscussionEG has been associated with overall mortality rates exceeding 50%. Early recognition and administration of antibiotics is essential to reduce mortality risk. Indications for laparotomy include perforation or uncontrolled sepsis.ConclusionEG can occur in diabetics with gastroparesis complicated by a bezoar and hyperemesis. Gastric pneumatosis is not an absolute indication for celiotomy as antibiotics and surgical vigilance may be appropriate and curative therapy.     

Ileal angiodysplasia presentation as a bowel obstruction: A case report

IntroductionAngiodysplasia is a common vascular abnormality of the gastrointestinal tract, found in the elderly and most frequently revealed by gastrointestinal bleeding. We report an original case of ileal angiodysplasia in an 83-year-old woman presenting as a bowel obstruction.Case presentationAn 83-year-old woman with a medical history of chronic untreated anemia, presented with cardinal symptoms of bowel obstruction. Computed tomography revealed diffuse ileal wall thickening with multiple zones of stenosis, which were aggravated by an ileal perforation and associated with vascular abnormalities compatible with angiodysplasia. Surgery confirmed the imaging findings. A large resection importing one meter of ileum was performed. The pathology report of the resected specimen revealed ischemic lesions of ileum associated with ileal angiodysplasia. The postoperative period was marked by an acute dehydration in the patient who died 3 weeks after surgery.DiscussionAngiodysplastic lesions develop with aging due to chronic low-grade intermittent obstruction of submucosal veins. These lesions are the result of increased contractility at the level of muscularis propria, leading to congestion of the capillaries and failure of pre-capillary sphincters, resulting in the formation of small arteriovenous collaterals. The acquired arteriovenous malformation consisting of multiple shunts with rapid blood flow may result in inadequate oxygenation of a segment of the intestine and lead to ischemia and eventually wall thickening, stenosis and even perforation of the small bowel.ConclusionAngiodysplasia should be kept in the back of one’s mind as one of the causes of acute abdomen and bowel obstruction, especially in elderly people suffering from occult gastrointestinal bleeding.     

Phytobezoars as a cause of small bowel obstruction associated with a carcinoid tumor of the ileocecal area

Carcinoid tumors are slowly growing malignant neoplasms associated with an indolent clinical course. About 60% of such tumors are located within the gastrointestinal tract. We describe an unusual case of small bowel obstruction associated with a carcinoid tumor of the ileum. A 70-year-old woman was presented with abdominal pain, vomiting, and clinical signs of mechanical bowel obstruction. X-ray and CT-scan of the abdomen showed hydroaeric levels and the presence of intraluminal hyperdense "stones", presumably of gallbladder origin. A diagnostic laparotomy revealed that a large part of the terminal ileus was edematous, with prominent evidence of intestinal loop adhesions. The edematous part of the ileum was resected. Incision of the intestinal wall revealed a 2-cm soft mass at 8 cm from the ileocecal valve, where the presence of ten fruit pits obstructed the intestinal cavity. Histopathological examination confirmed the diagnosis of a carcinoid tumor. An interesting case of small-bowel obstruction with a double cause is presented: an ileal carcinoid and fruit pit bezoars. The pathophysiology of the obstruction is discussed.     

Intermittent small bowel obstruction by jejunal enteroliths in a patient with a Crohn's disease stricture

Small bowel obstruction is most frequently due to postoperative or inflammatory adhesions, intestinal neoplasms, hernias, or bezoars. Intermittent small bowel obstruction may be secondary to a Crohn's disease stricture or to chronic adhesive peritonitis. Enterolithiasis, usually associated with jejunal diverticulosis or with a Meckel diverticulum, should be considered in patients who have not previously undergone abdominal surgical procedures. X-ray evidence of stones in the abdominal field, outside the common sites, i.e. gallbladder, kidney, bladder, should suggest a diagnosis of enterolithiasis. The authors report a case of multiple enteroliths in a patient with a segmental ileal stricture and ulcerations (diagnosed as Crohn's disease) causing frequent, intermittent occlusive symptoms, treated by segmental ileal resection.     

Giant enterolith in ileal diverticulum following ileoplastic bladder augmentation

INTRODUCTIONWhen adhesions, internal hernias, malignant intra- and retro-peritoneal neoplasms are excluded in patients presenting with new onset constipation and abdominal mass appearance after previous abdominal surgery, other causes must be considered.PRESENTATION OF CASEGiant enteroliths formed within ileal diverticula in the site of small bowel anastomosis may extrude and produce a palpable abdominal lump. Recent experience with such a patient is the basis of this report.DISCUSSIONIleal diverticula with interior enteroliths may be suspected in patients presenting with an abdominal lump following previous small bowel resection.CONCLUSIONOpen or laparoscopic assisted surgical resection of the involved segment is the treatment of choice.     

Acute Organoaxial gastric volvulus: A massive problem with a twist-case report

IntroductionGastric volvulus (GV) is a rare and life threatening condition if not treated promptly or wrongly diagnosed. The main complication of gastric volvulus is foregut obstruction. The extreme rotation can cut off blood supply to the stomach and even distal organs, which can lead to ischemia and necrosis of the affected area.Presentation of caseWe report a case of a 41yo female that complained of severe abdominal pain, nausea and vomiting for approximately 3 days after eating a large meal. The patient didn’t have any flatus or bowel movements in the last 24 h. CT of the abdomen and pelvis showed a dilatation of the stomach and esophageal hernia. Laparotomy confirmed an organoaxial volvulus at the level of the antrum and body of the stomach. Gastropexy was implemented and the stomach fixed to the posterior abdominal wall to prevent recurrence.DiscussionGV may have a significant related morbidity and mortality rate. It can be missed easily on diagnosis. The presence of vomiting not responding to initial antiemetic treatment, as well as, the presence of a hiatal hernia on the imaging studies should trigger our thinking of gastric volvulus, regardless of the stable appearance of the patient.ConclusionChronic GV can manifests as atypical chest, abdomen and gastro intestinal symptoms. We recommend that everyone with these atypical symptoms seek medical attention to rule out GV. Early diagnosis and treatment will reduce the risk of developing chronic gastric volvulus to acute gastric volvulus.     

An incidentally identified 15 cm cavernous hemangioma of the small intestine: Case report and literature review

IntroductionHemangiomas of the small intestine are rare, usually present with symptoms such as anemia, gastrointestinal bleeding or abdominal pain and are resected. We report resection of an incidentally identified cavernous hemangioma of the small intestine that did not present symptoms referable to the hemangioma. Although it was a large lesion, it was resected using laparoscopy and a mini-laparotomy.Presentation of caseA 29-year-old otherwise healthy man was referred for evaluation of ileal wall thickening found on a contrast-enhanced computed tomography scan obtained for the workup of chronic diarrhea. Double balloon enteroscopy (DBE) showed a cavernous hemangioma of the small intestine. The lesion was 15 cm and resected using laparoscopy and a mini-laparotomy to prevent future bleeding. The histopathological diagnosis was a cavernous hemangioma of the ileum.DiscussionThough there have been no reports of the asymptomatic patients of the disease, the recent spread of double balloon enteroscopy and capsule endoscopy will allow us to diagnose more asymptomatic hemangiomas like this patient. Also, this large lesion was able to be resected through a small incision due to its compressible nature.ConclusionFuture studies in asymptomatic patients of the disease may help to determine the optimal management for these patients. Even large hemangiomas are compressible, facilitating minimally invasive resection.     

Laparoscopic management of appendicular mucinous cystadenoma,case report

IntroductionAppendectomy is the most common emergency surgical procedure performed worldwide. Mucinous cystadenoma is a rare benign tumor of the appendix. There is no agreement on the best surgical approach for its management. Recently, laparoscopic approach is being increasingly tried. Careful excision of the tumor is mandatory to avoid content spillage into peritoneum resulting in pseudomyxoma peritonei.Case presentationA middle-age male patient presented to the emergency department complaining of chronic abdominal pain, bleeding per rectum and recurrent attacks of vomiting. Preoperative imaging confirmed presence of cystic lesion in the right lower quadrant. He underwent a diagnostic laparoscopy with resection of appendicular mucocele. The histopathological examination confirmed the diagnosis of appendicular mucinous cystadenoma. He was followed up in the clinic for two years.ConclusionAppendicular mucinous cystadenoma should be considered in differential diagnosis of cystic mass detected in the right lower quadrant of the abdomen on US or CT. Laparoscopic excision of the tumor is safe and feasible with extra care taken to avoid pseudomyxoma peritonei.’     

Large mesenteric cyst mimicking an ovarian cyst in an 8-year-old: A case report

Introduction and importancePediatric mesenteric cysts, rare and usually benign intra-abdominal tumors, are a difficult preoperative diagnosis due to ambiguous clinical characteristics. The final diagnosis is typically established only during surgery or histological analysis.Case presentationAn 8-year-old female presented with five days of worsening abdominal pain, associated with nausea, vomiting, and fever, as well as vague tenderness in the right quadrants on examination. Computed tomography imaging showed a 10.5 × 8.7 × 7 cm abdominal mass, most suspicious for a cystic mass of ovarian origin. Upon diagnostic laparoscopy, a mesenteric cyst extending to the root of the mesentery was visualized and entirely resected after conversion to an exploratory laparotomy. Histopathological examination of both the cystic fluid and specimen suggest a benign mesenteric cyst.Clinical discussionAlthough mesenteric cysts are noticeably rare, it is important differential to consider in pediatric patients with non-specific symptoms like abdominal pain and distention, intestinal obstruction, or a palpable abdominal mass. Notably, these cysts can be managed successfully by complete surgical resection with an excellent outcome.ConclusionThis report recounts an interesting case of a large mesenteric cyst that mimicked an ovarian cyst in a pre-pubertal girl.     

Rare cause of small bowel obstruction secondary to epiploic appendagitis: Diagnostic dilemma and role of minimal invasive surgery

Acute abdomen is the most common emergency surgical presentation, often caused by small bowel obstruction (SBO). There are many underlying causes of SBO, of which post-operative adhesions are the commonest. Acute epiploic appendagitis is a rare cause of SBO with only a few reported cases in the literature. We report a rare case of SBO secondary to sigmoid appendagitis presenting with colicky epigastric pain and delayed onset obstructive symptoms (intractable vomiting and constipation).We chose to highlight this case given the unusual presentation and diagnostic dilemma, particularly the unusual localisation of pain. In addition, we wanted to highlight the laparoscopic management of this case, as opposed to laparotomy (described in the literature), which minimised surgical morbidity for the patient.     

An unusual presentation of an adrenal tumour–a case report

Introduction and importanceAdrenal myelolipomas are rare, benign tumours with an incidence of 0.08–0.2%. They present between the fifth and seventh decade of life [1].Case presentationOur patient presented with complaints of vomiting and left lumbar pain of four weeks duration. Blood work revealed dyselectrolytemia. Contrast enhanced computed tomography of the abdomen and pelvis confirmed the diagnosis and the patient was planned for an adrenalectomy. Histopathology report revealed the pathology. She is currently on routine follow up and is disease free. Written informed consent was obtained from the patient for publication of this case report and its accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. This case report has been reported in line with the SCARE criteria [2].Clinical discussionWith the increased use of imaging modalities of the abdomen, they are now considered to be the second most common cause of adrenal incidentalomas (6–16%) [3]. Most tumours are small, asymptomatic and often go undiagnosed. Large tumours can cause chronic pain and other nonspecific symptoms.ConclusionThough myelolipomas are identified on routine CT scans, on a background of dyselectrolytemia, a further evaluation is of utmost importance to rule out the possibility of a functioning tumour.     

Acute cholecystitis due to a gall bladder torsion

IntroductionGallbladder torsion is an unusual cause of an acute abdomen that can be mortal. It is presenting in variable ways, but the most common is symptomatology similar to acute cholecystitis. Clinical manifestations and imaging features can facilitate diagnosis, and treatment is detorsion with cholecystectomy.Case presentationA 26-year-old male presented to the emergency department with intense abdominal pain, vomiting. The patient did not respond to symptomatic treatment and continued to present pain, nausea, and vomiting. The Ct scan showed signs of acute cholecystitis. The patient underwent laparoscopic cholecystectomy and found that the gallbladder was gangrene, enlarged due to torsion. Detorsion and cholecystectomy were carried out without complications.     

Bowel obstruction secondary to an ectopic pancreas in the small bowels: About 2 cases

IntroductionEctopic pancreas is most commonly found in the jejunum and stomach. Most patients remain asymptomatic, and the diagnosis is usually made at autopsy or incidentally. We report here 2 cases of intestinal occlusion, secondary to an ectopic pancreatic tissue. Both cases were managed successfully by laparoscopy and laparotomy with subsequent segmental intestinal resection.Case presentationsCase 1 – An elderly patient presented to the ER because of intestinal occlusion. Paraclinical investigations were consistent with occlusion, with ileal suffering signs on CT-scan. After laparotomy and segmental intestinal resection were done, histopathalogy showed evidence of ectopic pancreas obstructing the intestinal lumen. Case 2 – A young man presented to the ER with acute onset of epigastric pain. signs of peritoneal irritation. Ct-scan showed evidence of small bowel intussusception. Exploratory laparoscopy was done, and confirmed the diagnosis. The intussusceptum was at the level of the proximal jejunum. The suffering intestinal part was exteriorized and then resected. Histopathology was consistent with an ectopic pancreas.DiscussionSymptomatic ectopic pancreas is extremely rare. Symptoms may include, bleeding, intestinal occlusion and intussusception. Few similar cases have been reported in the literature, and the current ones are to be added.ConclusionAs mentioned above, ectopic pancreatic tissue rarely causes symptoms. We presented 2 cases that presented 2 possible complications secondary to this pathology. Both cases were managed successfully.     

Acute pancreatitis secondary to a prolapsed gastric fundal GIST

INTRODUCTIONGastrointestinal stromal tumours (GISTs) account for less than 3% of all gastrointestinal tract tumours and 5.7% of all sarcomas, and the majority of these tumours are gastric in origin. Patients commonly present with gastrointestinal bleeding or abdominal pain with 10–30% of patients presenting with symptoms of gastrointestinal obstruction.PRESENTATION OF A CASEWe present a case of a 65-year-old gentleman who presented with symptomatic iron deficiency anaemia. Gastroscopy revealed a large submucosal lesion originating from the gastric fundus, consistent with a GIST. The patient developed acute epigastric pain, vomiting with raised inflammatory markers. A CT of the abdomen revealed the GIST to be causing gastric outlet obstruction as result of a prolapse of the tumour through the pylorus into the duodenum. This also resulted in compression of the distal common bile duct and was associated with the radiological appearance of acute pancreatitis. This responded to conservative management. The GIST was resected subsequently using a laparoscopic technique.DISCUSSIONOnly one similar case has previously been reported in the literature. Several surgical approached have been described in the management of gastric GISTs including open, laparoscopic, hand assisted, ultrasound assisted and a combined endoscopic and laparoscopic approach. A laparosopic ‘eversion’ techinque was preferred in our case due to the close proximity of the tumour to the gastro-oesophageal junction.CONCLUSIONPancreatitis secondary to a prolapsed gastric GIST is a rare entity. Laparoscopic wedge resection of these tumours can be safely performed with a satisfactory oncological outcome.     

Bilateral ileal ureter substitution for patients with ureteral strictures secondary to gynecological tumors radiotherapy: a multi-center retrospective study

BackgroundThe selection of treatment for bilateral ureteral strictures caused by radiotherapy in patients with gynecological tumors often brings great challenges to urologists. This study was designed to analyze the characteristics of radiation-induced ureteral strictures and summarize the surgical experience of bilateral ileal ureter substitution.MethodsWe retrospectively collected the medical records of 18 patients between June 2010 and June 2019 who had a radiation-induced bilateral ureteral strictures. Time interval from radiotherapy to the discovery of ureteral stricture was categorized into short-term (less than 12 months) and long-term (over 12 months) groups. All patients received reverse “7” bilateral ileal ureteral substitution. Surgical success was defined as no restenosis, relief of symptoms, and improved/stabilized hydronephrosis.ResultsThe patients had been suffered from ureteral stricture for a median of 12 [2–106] months. The mean length of the left and right ureteral stricture was 9.6±2.6 and 8.8±3.2 cm, respectively. The mean length of the ileal graft was 29.1±7.4 cm. The mean operative time was 308.4±70.2 min, and the mean estimated blood loss was 254.7±166.2 mL. The postoperative hospital stays in the short-term group was significantly shorter than that in the long-term group (14.0 vs. 20.6 days, P=0.049). During a median follow-up time of 24.1 (4.5–71.9) months, the success rate was 94.4%. Eight minor complications and two major complications occurred in 7 patients.ConclusionsBilateral ileal ureter substitution can be an effective strategy for radiation-induced ureteral stricture in patients with gynecological tumors.     

Small bowel obstruction and ileocolic fistula caused by post-myomectomy Gossypiboma transmural migration: A case report and review of the literature

IntroductionPost-myomectomy Gossypiboma causing Ileo-colic fistula is tremendously rare; it may present as a tumor and stand a diagnostic challenge. The duration between the primary procedure and the presentation is unpredictable.Case presentationA 37-year-old Sudanese/African woman presented with a 4-month history of left iliac fossa mass, pain, anorexia, and persistent, recurrent vomiting with episodes of diarrhea during the last month PTP. She had two gynecological surgeries. Abdominal X-ray & abdominopelvic CECT showed a left iliac fossa pelvic-abdominal collection, distal small bowel partial obstruction, and contrast passage from the small bowel to the sigmoid colon. Diagnosis retained foreign body with abscess causing distal ileal subacute obstruction and an ileo-sigmoid fistula. Surgical exploration, extraction of Gossypiboma with small bowel resection, primary sigmoid colon repair, and a protective transverse colon stoma were done. Six weeks later, colostomy closed after distal loopogram and flexible-sigmoidoscopy.Clinical discussionA missed intraperitoneal gauze is the top differential diagnosis in patients presenting with acute abdomen after recent abdominal surgery. Transmural migration is slow but leads to difficult clinical situations, peritonitis, or fistulas. Our case reflects the light on the importance of the golden rule of perioperative gauze count and documentation. Thus, minimizing the surgical complications and preventing severe postoperative morbidities.ConclusionEntero-colic fistula due to trans mural migration is not frequently encountered, and its complications can lead to morbidities and even mortality if not promptly diagnosed and treated. Strict adherence to the golden rule of counting and prevent such life-threatening complications and improves patients' safety.