Asymptomatic Woman Research Articles

The Migration of an Intrauterine Device in the Bladder of an Asymptomatic Woman: A Case Report

Background: The use of intrauterine devices (IUDs) for contraception has increased in many countries. However, their application has some serious complications such as uterine perforation and injury to adjacent organs. The translocated IUD into the bladder is a very rare occurrence. Case Presentation: Our case was a 41-year-old woman whose IUD was accidentally discovered in her bladder during a routine ultrasound. The IUD has migrated from its normal position in the uterus to the bladder. The IUD was successfully removed by cystoscopy without any complications. Conclusion: The mislocation of an IUD in the bladder, while uncommon, is a possibility that should be considered when the IUD string is not visible during examinations.

Intravenous iron preoperatively for woman with severe anaemia

Iron deficiency is the main cause of anaemia, especially in premenopausal due to heavy menstrual bleeding. In this case report, an asymptomatic woman presented with a haemoglobin level of 3.9 mmol/l. Due to uterine fibroids, she was scheduled for myomectomy, and she was treated with IV iron. Fourteen days post infusion her haemoglobin level was 6.3 mmol/l. This highlights the importance of screening women for heavy menstrual bleeding causing iron deficiency, and encourage at-risk women to take iron supplements. Furthermore, one should be aware of IV iron therapy as an alternative to blood transfusion in treating iron deficiency anaemia.

Unus Pro omnibus, omnes Pro uno: a commentary on the eternal dilemma of endometrial cancer screening in postmenopausal asymptomatic women. Is it time to team up?

Introduction The diagnostic workflow for endometrial carcinoma in postmenopausal asymptomatic women remains an ongoing dilemma. Whereas an ultrasonographic endometrial thickness greater than 4.0 or 5.0 mm is adequate for warranting further investigations in women with postmenopausal vaginal bleeding, there is still no unanimous consensus on what the ideal endometrial thickness cut-off should be, justifying additional inspection through endometrial sampling when bleeding is absent. Methods A comprehensive overview of the most recent literature to summarize the clinical pathway necessary for the diagnostic assessment of a postmenopausal asymptomatic woman with increased ultrasonographic endometrial thickness. Results An endometrial thickness cut-off between 3.0 and 5.9 mm seems to show the lowest specificity while also reducing the chances of missing malignancy. If endometrial thickness can be a valid starting point, a careful evaluation of the other ultrasonographic endometrial features and a thorough scrutiny of patients’ risk factors are pivotal to standardizing the diagnostic process while avoiding overtreatment. Although preventing unnecessary procedures is crucial, stratifying the risk and proceeding with further investigations (preferably through outpatient or office hysteroscopically-guided targeted biopsies) should be the goal. Conclusions Closer collaboration between different fields of medicine (ultrasonography, hysteroscopy, and oncology) is strongly encouraged to facilitate early diagnosis of asymptomatic postmenopausal women at risk of developing endometrial malignancy.

Symptomatic Foveal Impingement following Posterior Vitreous Detachment Formation

A-57-year old visually asymptomatic healthy woman was examined by us first in 2016. On optical coherence tomographic (OCT) examination left foveal contour appeared as normal at that time (Figure A). In 2020, there was the evidence of vitreomacular adhesion despite the normal foveal contour in the left eye (Figure B). However, we noticed the left foveal inpingement related to detached posterior vitreous on OCT when she was reexamined with the complaint of left metamorphosia in 2024 (Figure C). Posterior vitreous detachment (PVD) is the vitreous gel liquefaction,and extracellular matrix changes at the vitreoretinal interface characterized with the detachment of posterior vitreous cortex from the internal limiting membrane due to ongoing aging process.1 Gel liquefaction that exceeds the degree of vitreoretinal dehiscence may end up with anomalous PVD. We propose the term of ‘foveal inpingement’ to describe the subtle foveal contour change described above and believe that this term can gain recognition among the retinal physicians.

In Situ Analyses of Placental Inflammatory Response to SARS-CoV-2 Infection in Cases of Mother-Fetus Vertical Transmission.

It has been shown that vertical transmission of the SARS-CoV-2 strain is relatively rare, and there is still limited information on the specific impact of maternal SARS-CoV-2 infection on vertical transmission. The current study focuses on a transcriptomics analysis aimed at examining differences in gene expression between placentas from mother-newborn pairs affected by COVID-19 and those from unaffected controls. Additionally, it investigates the in situ expression of molecules involved in placental inflammation. The Papa Giovanni XXIII Hospital in Bergamo, Italy, has recorded three instances of intrauterine transmission of SARS-CoV-2. The first two cases occurred early in the pandemic and involved pregnant women in their third trimester who were diagnosed with SARS-CoV-2. The third case involved an asymptomatic woman in her second trimester with a twin pregnancy, who unfortunately delivered two stillborn fetuses due to the premature rupture of membranes. Transcriptomic analysis revealed significant differences in gene expression between the placentae of COVID-19-affected mother/newborn pairs and two matched controls. The infected and control placentae were matched for gestational age. According to the Benjamani-Hochberg method, 305 genes met the criterion of an adjusted p-value of less than 0.05, and 219 genes met the criterion of less than 0.01. Up-regulated genes involved in cell signaling (e.g., CCL20, C3, MARCO) and immune response (e.g., LILRA3, CXCL10, CD48, CD86, IL1RN, IL-18R1) suggest their potential role in the inflammatory response to SARS-CoV-2. RNAscope® technology, coupled with image analysis, was utilized to quantify the surface area covered by SARS-CoV-2, ACE2, IL-1β, IL-6, IL-8, IL-10, and TNF-α on both the maternal and fetal sides of the placenta. A non-statistically significant gradient for SARS-CoV-2 was observed, with a higher surface coverage on the fetal side (2.42 ± 3.71%) compared to the maternal side (0.74 ± 1.19%) of the placenta. Although not statistically significant, the surface area covered by ACE2 mRNA was higher on the maternal side (0.02 ± 0.04%) compared to the fetal side (0.01 ± 0.01%) of the placenta. IL-6 and IL-8 were more prevalent on the fetal side (0.03 ± 0.04% and 0.06 ± 0.08%, respectively) compared to the maternal side (0.02 ± 0.01% and 0.02 ± 0.02%, respectively). The mean surface areas of IL-1β and IL-10 were found to be equal on both the fetal (0.04 ± 0.04% and 0.01 ± 0.01%, respectively) and maternal sides of the placenta (0.04 ± 0.05% and 0.01 ± 0.01%, respectively). The mean surface area of TNF-α was found to be equal on both the fetal and maternal sides of the placenta (0.02 ± 0.02% and 0.02 ± 0.02%, respectively). On the maternal side, ACE-2 and all examined interleukins, but not TNF-α, exhibited an inverse mRNA amount compared to SARS-CoV-2. On the fetal side, ACE-2, IL-6 and IL-8 were inversely correlated with SARS-CoV-2 (r = -0.3, r = -0.1 and r = -0.4, respectively), while IL-1β and IL-10 showed positive correlations (r = 0.9, p = 0.005 and r = 0.5, respectively). TNF-α exhibited a positive correlation with SARS-CoV-2 on both maternal (r = 0.4) and fetal sides (r = 0.9) of the placenta. Further research is needed to evaluate the correlation between cell signaling and immune response genes in the placenta and the vertical transmission of SARS-CoV-2. Nonetheless, the current study extends our comprehension of the molecular and immunological factors involved in SARS-CoV-2 placental infection underlying maternal-fetal transmission.

Successful thoracoscopic enucleation of a calcifying fibrous tumor of the lower mediastinum in a young woman

BackgroundCalcifying fibrous tumor (CFT) arising from the pleura is a relatively rare benign lesion in young and middle-aged adults. We report a 31-year-old woman with pleural CFT who underwent successful complete thoracoscopic enucleation.Case presentationAn asymptomatic woman presented with a mass in the right lower lung field that was incidentally detected on a chest X-ray during a routine medical checkup. Chest computed tomography showed a well-defined mass in the lower mediastinum, with a maximum diameter of approximately 5.5 cm. Esophagogastroduodenoscopy showed no abnormal findings in the esophagus. An endoscopic ultrasonography (EUS) revealed a well-defined tumor with no internal blood flow. EUS-fine needle aspiration failed to establish a definitive diagnosis. Therefore, thoracoscopic tumor enucleation was performed for diagnostic and therapeutic purposes. Based on the histopathological findings of the resected specimen, the presence of a tumor with a high fibrous component in a young woman, and the identification of granulomatous calcifications, a diagnosis of CFT was established.ConclusionsComplete thoracoscopic tumor enucleation was successfully performed for CFT arising from the pleura in a young adult woman.

#2538 Asymptomatic perirenal lymphoma: an unusual presentation of primary lymphoma

Abstract Background and Aims Isolated perinephric lymphoma is uncommon clinicopathological entity, reported in less than 10% of cases. Although this is rare finding, every perirenal mass require prompt diagnosis and multidisciplinary approach if needed. Method We described a case of a asymptomatic young woman who presented with accidental ultrasound finding of a „kidney sweat sign“. Results A 40 year old woman was reported to nephrologist after ultrasonography incidentally revealed a „kidney sweat sign“. The patient had normal kidney function and was symptom-free. Also, all laboratory findings were within the reference range. She was admitted to the nephrology department and CT urography, followed by the ultrasound guided coarse needle biopsy was performed. CT scan revealed right perirenal area completely filled with soft tissue mass that was making an external compression of the right kidney with no infiltration of renal tissue, while pathohistology examination of the biopsy core showed non Hodgkin B cell lymphoma of marginal zone. Immunohistochemistry study demonstrated CD20+, CD3-,CD5-, bcl 2+, bcl 6-, CD10-, CD21-, CD23-, CD38+, cyclin D1-, Ki67+ in 5–10 tumor cells. The patient was reported to hematologist where she underwent bone marrow biopsy which did not show evidence of lymphoma involvement. She was initiated on chemotherapeutic treatment R- COP (Rituximab, cyclophosphamide, vincristine and prednisone). Until now she received three doses of immunochemotherapy and showed good response to the therapy with decrease in the mass dimensions at the repeated CT scan without signs of disease dissemination. Conclusion This case report highlights the importance of an urgent and expeditious work up, including both CT scan and biopsy. Multidisciplinary approach in order to get timely diagnosis and treatment are imperative to achieve improved outcomes.

Placental inflammation in a fetal demise of a SARS-CoV-2-asymptomatic, COVID-19-unvaccinated pregnant woman: a case-report

BackgroundIntrauterine fetal demise is a recognized complication of coronavirus disease 2019 in pregnant women and is associated with histopathological placental lesions. The pathological mechanism and virus-induced immune response in the placenta are not fully understood. A detailed description of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced inflammation in the placenta during fetal demise is crucial for improved clinical management.Case presentationWe report the case of a 27-week gestation SARS-CoV-2-asymptomatic unvaccinated pregnant woman without comorbidities or other risk factors for negative pregnancy outcomes with a diagnosis of intrauterine fetal demise. Histopathological findings corresponded to patterns of subacute inflammation throughout the anatomic compartments of the placenta, showing severe chorioamnionitis, chronic villitis and deciduitis, accompanied by maternal and fetal vascular malperfusion. Our immunohistochemistry results revealed infiltration of CD68+ macrophages, CD56+ Natural Killer cells and scarce CD8+ T cytotoxic lymphocytes at the site of placental inflammation, with the SARS-CoV-2 nucleocapsid located in stromal cells of the chorion and chorionic villi, and in decidual cells.ConclusionThis case describes novel histopathological lesions of inflammation with infiltration of plasma cells, neutrophils, macrophages, and natural killer cells associated with malperfusion in the placenta of a SARS-CoV-2-infected asymptomatic woman with intrauterine fetal demise. A better understanding of the inflammatory effects exerted by SARS-CoV-2 in the placenta will enable strategies for better clinical management of pregnant women unvaccinated for SARS-CoV-2 to avoid fatal fetal outcomes during future transmission waves.

A rare case of intravascular leiomyomatosis from ovaric vein to right atrium in an asymptomatic woman.

A rare case of intravascular leiomyomatosis from ovaric vein to right atrium in an asymptomatic woman.

Multimodal Retinal Imaging Reveals New Pathogenic Insights in Central Areolar Choroidal Dystrophy: A Case Series.

To describe novel imaging findings in a family affected by central areolar choroidal dystrophy (CACD). Case series with multimodal retinal imaging assessment. A 19-year-old asymptomatic woman was referred for bilateral macular defects of the retinal pigment epithelium (RPE). Blue-light autofluorescence (BAF) of her right eye revealed a speckled pattern in the macular area with a ring of decreased autofluorescence using near-infrared autofluorescence (NIR-AF). Multimodal assessment of her left eye disclosed a single parafoveal spot of decreased pigmentation that was clearly visible as hyper-autofluorescent using BAF and as hypo-autofluorescent using NIR-AF. Optical coherence tomography angiography (OCT-A) revealed several tiny areas of flow voids in correspondence of the RPE alterations of both eyes.Three family members were recently diagnosed with presumed age-related macular degeneration and demonstrated well-demarcated areas of RPE atrophy surrounded by yellowish deposits and a hypo-pigmented halo.Next-generation genetic analysis for inherited macular dystrophies was performed on the index case and the affected family members and revealed a p.Arg172Gln missense mutation in PRPH2 gene, leading to the diagnosis of CACD. Multimodal imaging can reveal new pathogenic insights in CACD. Of notice, NIR-AF and OCT-A are able to detect RPE hypopigmentation and choriocapillaris rarefaction, respectively, since the earliest stages of the disease.

Mid-Trimester Spot Urinary Albumin/Creatinine Ratio as a Screening Tool in Prediction of Pre-eclampsia.

To determine utilization of spot urinary albumin/creatinine ratio (UACR) to predict subsequent development of preeclampsia, measured between 17 and 24weeks of gestational age in asymptomatic antenatal woman and determine their maternal and neonatal outcomes. In preeclampsia the basic pathology is generalized endothelial dysfunction. It causes glomerular endotheliosis which leads to proteinuria, decreased glomerular filtration rate and renal blood flow. Thus microalbuminuria is an early marker which can measured to predict preeclampsia. It is a prospective observational study, carried out for one year in a cohort of asymptomatic antenatal women at 17-24weeks of gestational age, attending hospital for routine antenatal check-up with a singleton pregnancy and no associated complications. Urine albumin and creatinine ratio (UACR) is measured at first visit, and women were followed till delivery and the maternal and foetal outcomes were recorded. Out of 81 pregnant women enrolled in the study, 58% belonged to 18-25years, 54.3% belonged to lower middle class. There was a significant difference in mean UACR among women who developed preeclampsia (PE) and gestational diabetes mellitus (GDM) with p value < 0.05. In the study there was significant association between severe PE, PE and GDM with UACR at 22 as cut-off, with p value < 0.05. In the study among those with UACR > 22, 2.5% had IUFD, 12.5% had LBW, and 7.5% were admitted to NICU. With the measurement of spot UACR in mid-trimester we can predict the development of preeclampsia before the onset of clinical manifestations. UACR > = 171mg/g predicted preeclampsia well before the onset of clinical manifestations with high sensitivity of 83.3% and specificity of 98.6%. The online version contains supplementary material available at 10.1007/s13224-023-01862-9.

Distinguishing Glial Tissue from Optic Disc in Bergmeister's Papilla Using OCT Angiography

A 55-year-old asymptomatic woman was found to have bilateral abnormalities of the optic nerve during an ophthalmic examination. Ocular examination revealed visual acuity of 20/20 in both eyes with normal anterior segment. Fundus examination showed grayish-white glial tissue covering the optic nerve (A) as confirmed by infrared image (B) from OCT. Cross-sectional OCT image (C) exhibited hyperreflective membrane overlying the optic disc, and adhesions to adjacent optic papilla structure (white arrow). The corresponding OCT angiography B-scan with flow overlay (D) showed hyperreflective tissue without any flow signal, contrasting with the optic disc's normal blood flow signal (Magnified version of Figure A-D is available online at www.aaojournal.org).

Pneumatosis cystoides intestinalis: when the location of the air may be a pitfall

Pneumatosis cystoides intestinalis (PCI) is a rare and generally benign condition characterized by air within the walls of the small intestines or colon. Moreover, it may be a cause of free air in peritoneum. To correctly manage this entity when found at CT, it is of crucial importance for the radiologist to recognize and distinguish it from life-threatening causes of pneumatosis intestinalis or pneumoperitoneum. This differentiation may be challenging and the absence of additional findings (bowel wall thickening, altered contrast mucosal enhancement, fat stranding, dilated bowel, ascites, and the presence of portal venous gas) may be very helpful in suggesting the diagnosis. In this short communication we present a case of PCI in an asymptomatic 60-year old woman with a history of uterine carcinoma. The patient underwent a colonoscopy after a positive result of fecal occult blood test; the colonoscopy showed the presence of multiple grape-like nodules in the splenic flexure of the colon and biopsies were performed to exclude malignity of the findings. Then, a CT was conducted and it showed the presence of multiple, thin-walled, air-filled submucosal cysts in the splenic flexure of the colon. The endoscopic and CT findings, together with the absence of abdominal symptoms and altered laboratory test, allowed to establish the diagnosis of PCI. The patient was managed conservatively. Moreover, some free air bubbles were found in the pneumoperitoneum at one-year and two-year follow-up CTs, without abdominal symptoms.

C47 ADAPTATION OF THE PULMONARY CIRCULATION AND OF THE RIGHT HEART IN INTRACARDIAC INVETERATE SHUNTS: UNDER PRESSURE OR LET IT FLOW?

Abstract Congenital heart disease can be associated with pulmonary hypertension (PH) development and heart right remodelling. Nevertheless, the adaptation of the pulmonary circulation and of the right heart can be extremely heterogeneous, so that an accurate diagnostic work up may be advisable when an intracardiac shunt is suspected. Case Presentation A 53 years old woman, with no relevant clinical history and asymptomatic, was incidentally found to have clinical, ECG and echocardiographic signs of PH, and was referred to our Center. Diagnostic and Therapeutic Work Up Echocardiography showed: normal left ventricle (LV 3D volumes 88/35 ml), mild left atrial dilatation (39 ml/m2); severe right chambers dilatation (RV 3D 347/124 ml, EF 3D 62%, AD 116 ml/m2), moderate tricuspid regurgitation with a regurgitant jet velocity of 2.9 m/s. Right heart catheterization showed normal pulmonary pressures at rest (mPAP 20, PAWP 5 mmHg), extremely high pulmonary blood flow (Qp 29 L/min, calculated with the direct Fick method), with normal pulmonary vascular resistance (PVR 0.5 WU). During the oxymetric run, a step up in hemoglobin saturation between superior vena cava and right atrium (from 74 to 97%) was found, with a Qp/Qs ratio of 5.5. During exercise, Qp reserve was normal, suggesting a normal contractile reserve function of RV despite the extreme dilatation. Additionally, the patient did not develop exercise PH and exercise capacity was normal, based on a measured oxygen consumption (VO2) at peak of 24 ml/kg/min (104% of predicted). Angio–CT of the chest was performed, confirming the presence of a sinus venosus atrial septal defect. The patient was then referred for surgical correction. Conclusion Echocardiography signs are useful to direct correctly diagnostic work up. A severe RV dilatation with normal systolic function in an asymptomatic middle age woman should raise the possibility of an intracardiac shunt. Despite a large intracardiac shunt with a high Qp/Qs ratio for decades, PVR was normal, confirming that individual predisposition may play a role in the development of PH in pre–tricuspid shunts. Exercise test showed an optimal RV reserve, suggesting a low cardiac surgery risk.

Displaced bronchus and anomalous pulmonary vein passing dorsal to the pulmonary artery in a patient who underwent right upper lobectomy for lung cancer with lymph node metastases: a case report

BackgroundTracheobronchial anomalies are extremely rare and are often associated with pulmonary arteriovenous anatomical anomalies. An anomalous right upper vein segment that passes between the pulmonary artery (PA) and bronchus is a rare vascular abnormality. We report a case of a displaced superior posterior branch (B2) that was independent of the superior apical/anterior branch (B1 + 3) accompanied by anomalous right superior pulmonary vein (SPV) anatomy in a patient who underwent right upper lobectomy for lung cancer with lymph node metastases.Case presentationA 73-year-old asymptomatic woman was shown to have an abnormal shadow on chest radiography performed during medical checkup and visited our hospital for further evaluation. The patient was diagnosed with primary lung adenocarcinoma (c-T1cN1M0, stage IIB) involving the right superior posterior segment (S2) with an abnormally displaced B2 and an anomalous upper vein segment that was observed to run dorsal to the PA and anterior to the right upper bronchus. We performed right upper lobectomy and systematic hilar and mediastinal nodal dissection via video-assisted thoracoscopic surgery. Intraoperative findings revealed a displaced B2 bronchus independent from the B1 + 3 and an anomalous SPV, which was consistent with preoperative imaging findings.ConclusionPreoperative bronchoscopy and three-dimensional computed tomography angiography (3D-CTA) are essential to confirm bronchial bifurcation and vascular abnormalities to aid with meticulous surgical planning to select the optimal operative technique.

Epidermal Cyst in an Intrapancreatic Accessory Spleen.

A 59-year-old asymptomatic woman with no disease history presented to our institution for investigation of a pancreatic tail mass. Hematological parameters were within normal ranges, including serum carcinoembryonic antigen levels and carboxyhydrate antigen 19-9. Computed tomography revealed a strongly enhanced solid peripheral mass with an intracystic component in the pancreatic tail (Figure A, arrow). Magnetic resonance imaging revealed a cystic lesion on the T2 image surrounded by a solid component with density and intensity levels similar to those in the spleen parenchyma (Figure B, arrow). Endoscopic ultrasonography showed a solid hyperechoic 20-mm mass and an intracystic hypoechoic component showing stronger enhancement by Sonazoid (MSD Inc) than the pancreatic parenchyma (Figure C, arrow). Laparoscopic distal pancreatectomy was used for diagnosis. Pathological examination revealed a white and red sinus of the ectopic spleen in the pancreatic tail, with a unilocular cyst lined with stratified squamous epithelium, indicating an epidermal cyst in the intrapancreatic accessory spleen (Figure D, arrows). Most epidermal cysts in the intrapancreatic accessory spleen cases are found incidentally, typically as single monolobular cystic lesions in the pancreatic tail with a thickened cystic wall or solid components identical in density to the spleen on imaging examinations, making a definite preoperative diagnosis extremely difficult, resulting in unnecessary surgical intervention.

Complete Congenital Heart Block in the Offspring of an Asymptomatic Woman with Isolated High Titer Anti-Ro Antibody

Among pregnant women, 1-2% are anti-Ro positive and while half of them have symptoms of connective tissuedisease, the rest are asymptomatic. The presence of anti-Ro is of concern because of the risk of congenital heartblock in the child.We report the case of an asymptomatic 27-year-old G2P1(1001) woman, who presented with persistent fetalbradycardia in her 21st week of gestation (AOG) and was found to have elevated titers for anti-Ro (&gt;320 U/ml).Hydroxychloroquine 200 mg/day and prednisone 10 mg/day were given from the 33rd week of gestation up until the delivery. At 37 weeks AOG, she delivered a live male neonate with a complete heart block. On the 6th day of life, the infant remained bradycardic, hence a pacemaker was inserted and heart rate maintained at 100-120 bpm. On subsequent follow-ups, the mother and child did not develop any systemic manifestations and the infant was thriving well.While a diseased condition may not be apparent in a pregnant anti-Ro positive woman, the risk of neonatal lupus (NL) is demonstrated in this patient’s case. This report illustrates how prenatal care of an asymptomatic woman led to the discovery of a fetal abnormality and served to prepare the family and the medical team to ably handle the birth and subsequent care of a neonate with NL.

Hypertrophic cardiomyopathy and left ventricular non-compaction cardiomyopathy: two in one.

A 22-year-old asymptomatic Caucasian woman was referred because of an elevated NT-pro-BNP level (1225 ng/L, normal <125 ng/L) and a positive family history of unclear cardiomyopathy. Her electrocardiogram showed sinus rhythm, left axis deviation with signs of left ventricular (LV) hypertrophy, and repolarization abnormalities (Panel A). The transthoracic echocardiography revealed an asymmetrical LV hypertrophy without signs of left ventricular outflow tract obstruction at rest or under provocative Valsalva manoeuvre (Supplementary material online, Video S1). Imaging with cardiovascular magnetic resonance (CMR) confirmed asymmetrical LV hypertrophy with a maximum wall thickness of 18 mm. CMR also showed biventricular prominent trabeculation with multiple anterior, septal and inferior deep recesses (Panel B, Supplementary material online, Video S2) and a maximum ratio of non-compacted to compacted myocardium of 2.6 (Supplementary material online, Image). Biventricular volumes and global ejection fraction were normal with a mild hypokinesia of the hypertrophied LV segments. Late Gadolinium Enhancement and post-contrast T1 mapping demonstrated focal patchy fibrosis in the hypertrophied segments and at both right ventricular insertion points (Panel C, D).

An unexpected diagnosis in an asymptomatic young woman

An unexpected diagnosis in an asymptomatic young woman

S2486 Chilaiditi’s Sign: Should You Give Up or Persist?

Introduction: Chilaiditi’s sign is an incidental radiographic finding of the interposition of the bowel loop between the liver and the diaphragm. With an estimated worldwide prevalence of 0.028 - 0.25 %, this is commonly associated with older age and men. Below, we describe an unusual case of Chilaiditi’s sign incidentally found during a routine colonoscopy in a female patient Case Description/Methods: A 73-year-old asymptomatic woman was referred to the Endoscopy Unit for a surveillance colonoscopy. On physical examination, the patient had no abdominal pain or distension. CBC and CMP were unremarkable. Pediatric colonoscope was inserted via the rectum and reached the hepatic flexure. However, due to an acute angulation, the scope was not able to be advanced further and the procedure was therefore aborted prematurely. A CT scan of the abdomen and pelvis performed the same day identified interposition of the distal transverse colon and proximal ascending colon between the liver and the anterior abdominal wall, which explained the difficulty encountered in advancing the colonoscope beyond the hepatic flexure (Figure). She is being rescheduled for repeat colonoscopy. Discussion: Acute angulation of the bowel and technical difficulty in completing a colonoscopy may be indicative of Chilaiditi’s sign. Predisposing factors include: cirrhosis, COPD, or presence of ascites. When this anatomical distortion becomes symptomatic, it is referred to as Chilaiditi’s syndrome. These symptoms are secondary to elevation of the diaphragm and/or bowel obstruction, perforation, or ischemia. It can be confirmed with CT imaging, which typically demonstrates an interposition of the transverse colon between the liver and the abdominal wall. While no intervention is usually required for asymptomatic patients with Chilaiditi’s sign, awareness of the condition is important for physicians. Forceful pressure against the interposed bowel can trap air in the colon segment and increase intra-luminal pressure, potentially causing perforation. To decrease the risk of perforation, carbon dioxide can be administered in patients with known Chilaiditi’ sign during colonoscopy as an insufflating agent. Limited case reports are available on the management protocol for patients with Chilaiditi’s sign; however, according to a previous case report, carbon dioxide is safe and effective in the GI tract. It is imperative that endoscopists are aware of this condition and exercise extreme caution while performing a difficult colonoscopy.Figure 1.: CT scan of abdomen showing the interposition of the distal transverse colon and proximal ascending colon between the liver and the anterior abdominal wall.