Brown Fluid Research Articles

Splenic Epidermoid Cyst arising within an Intrapancreatic Accessory Spleen Masquerading as a Pancreatic Mucinous Cystic Neoplasm-a diagnostic enigma

Abstract Introduction/Objective Accessory spleens are congenital embryological aberrations usually found within the splenic hilum with no clinical significance. An IntraPancreatic Accessory Spleen (IPAS) is an uncommon benign pancreatic lesion encountered clinically. A splenic epidermoid cyst arising within an IPAS is exceedingly rare and is discussed below. Methods/Case Report A 68-year-old male presented with intermittent post-prandial epigastric pain radiating to the left flank for >1.5 years. Radiological imaging identified a 5.2 cm calcified cyst in the pancreatic tail with a differential of mucinous pancreatic neoplasm/ pancreatic pseudocyst. Additionally, a 2.8cm lobulated solid hypoechoic mass was seen at the porta hepatis with a differential of enlarged lymph node/benign neoplasm. Laboratory biochemical tests were within normal limits except for mildly elevated ferritin. Fine needle aspiration biopsy was indeterminate. The patient elected to proceed with surgical resection. A laparoscopic distal pancreatectomy with splenectomy and excision of the hilar mass was performed. The hilar mass was analyzed by hematopathology and revealed a hyaline- vascular variant of Castleman disease. On gross examination of the distal pancreatic/splenectomy specimen, a well- demarcated cystic lesion with brownish fluid was noted within the pancreatic tail. Microscopic examination revealed a nonpathological pancreas separated by a fibrous capsule with a large cyst arising within an intrapancreatic accessory spleen. The cyst was lined with multilayered non-keratinized CK5/6, and p63 positive squamous epithelium with no lymphocytic infiltrates and absent hair/ dermal appendages confirming a splenic epidermoid cyst. Post-operative follow-up at 6 weeks was uneventful. Results (if a Case Study enter NA) NA Conclusion An epidermoid cyst arising within an intrapancreatic accessory spleen (ECIAS) is extremely rare thus precluding accurate preoperative diagnosis as this entity shares similar radiological imaging characteristics as other cystic lesions such as mucinous pancreatic cysts. It is important for anatomic pathologists to recognize and consider the intrapancreatic compartment as a possible location for accessory spleens. Accurate preoperative diagnosis can prevent unnecessary surveillance and/or extensive surgical resection.

7435 Thyroid Abscess Post-FNA in an Immunocompetent Host

Abstract Disclosure: B. Gautam: None. M.S. Hossain: None. S. Hossain: None. S.C. Kumar: None. H. liao: None. B. Tiwari: None. D.S. Rosenthal: None. Background: Thyroid Fine Needle Aspiration (FNA) is a common diagnostic procedure for thyroid nodules. Most common post FNA complications are minor pain, bruises and small hematomas. Despite being generally safe, FNA can occasionally lead to rare complications, such as thyroid abscess, especially in immunocompromised individuals. This case highlights the development of a thyroid abscess post-FNA in a 42-year-old immunocompetent female. Case Report: A 42-year-old female presented to ED with painful right sided neck lump. She had undergone FNA of right sided thyroid cyst, 10 days ago without any immediate complications as confirmed on post procedural ultrasonogram. She started having right sided neck pain after FNA which progressively got worse overtime associated with fever, chills and difficulty swallowing without any dyspnea or dysphonia. She denied symptoms of hyperthyroidism or hypothyroidism. Family history was significant for thyroid cancer in her mother and thyroid nodule in a sister. On exam: Temp. 101 F, HR 105 beats/min, BP 113/69 mm Hg, RR 18 breaths/min. Neck exam revealed soft, warm, tender mass in right neck region which was mobile with swallowing without any skin discoloration or discharge. The physical exam was otherwise unremarkable. Laboratory investigations showed elevated WBC 18000 (4.5-11 k/mm3) with absolute neutrophil count 14.4 (1.8-7 k/mm3), normal CMP. Thyroid hormone levels were normal: TSH 0.32 Uiu/ml, FT4 1.0 ng/dl), as were anti-TG ab, TSI and anti-TPO ab. CT scan of Neck with IV contrast showed a 2.8 x 2.5 x 3.8 cm homogeneous right thyroid mass with mass effect on the trachea. US thyroid showed a 3.7 x 2.9 x 3.3 cm right thyroid hypoechoic lesion with increased internal echogenicity and peripheral hyperemia, consistent with a thyroid abscess. Patient underwent IR guided drainage of 30 cc thick, dark brown fluid and started on broad spectrum IV antibiotics which was then modified based on the bacteriology report showing presence of gram-variable rods, specifically Corynebacterium, with significant clinical improvement. Discussion: The thyroid gland is considered resistant to infections because of its characteristics such as encapsulation, high iodine content and rich blood supply. Nevertheless, rarely, patients may develop post FNA complications including bacterial thyroiditis, thyroid abscess and retropharyngeal cellulitis, presenting with acute life-threatening complaints. This case highlights the importance of monitoring for these rare complications along with early diagnosis and treatment which involves drainage and targeted antibiotic therapy. In the presence of suspicious findings on ultrasonogram and a strong family history of thyroid cancer, we also like to emphasize rare cases where a thyroid abscess could originate from necrotizing cancer cell, the likely etiology of thyroid abscess in our patient. Presentation: 6/3/2024

Rare complications of acute pancreatitis: Clinical cases

Background. Acute pancreatitis is recognized as a common disease, occasionally accompanied by the development of local complications that require surgical debridement. Rare complications of pancreatitis may occur in clinical practice, which is one of the reasons for their untimely diagnosis and treatment. Pancreaticopleural fistula and high small bowel obstruction develop in less than 1% of acute pancreatitis cases. Therefore, possible options for management of these complications are considered valuable. Description of clinical cases. The clinical examples, provided in the present paper, describe pancreaticopleural fistula and high small bowel obstruction that develop against the peripancreatic mass in the abdominal cavity. Patient K., 44, was hospitalized to the Regional Clinical Hospital of Emergency Medical Care, Krasnodar Krai, and preliminary diagnosed with bilateral hydrothorax and type II respiratory failure; pleural puncture was performed. Following the extended examination, a clinical diagnosis was made as follows: “Acute necrotic pancreatitis spreading to a pancreatic tail cyst. Reactive double pleurisy”. The postoperative period was indicated with repeated recurrence of right hydrothorax, and pancreaticopleural fistula (diagnosed by measuring amylase activity in the brown fluid effused from the right pleural cavity, which appeared to be 41216 IU/l (not normally determined)). The right pleural cavity and pseudocyst of the pancreatic tail were drained, resulting in obliteration of the pancreatbcopleural fistula. Patient V., 50, was hospitalized and transferred to the surgical department of the Regional Clinical Hospital No. 2, Krasnodar Krai, and diagnosed with “pancreonecrosis, extensive purulent-necrotic peripancreatitis.” The patient underwent puncture-drainage treatment. The postoperative period was complicated by acute small bowel obstruction. Surgical treatment involved Braun enteroesterostomy. The patient recovered. Conclusion. Pancreaticopleural fistula refers to a rare complication of acute pancreatitis, manifested by hydrothorax. Its diagnosis is based on the determination of amylase activity in the effusion. Drainage of the pleural cavity and pancreatic pseudocyst contributes to obliteration of the fistula. The intestinal obstruction, another complication of pancreatitis, requires open surgical treatment when a conservative therapy appears ineffective.

Epidermoid Cyst arising within an Intrapancreatic Accessory Spleen [ECIPAS] mimicking a pancreatic mucinous cystic neoplasm-a case report with literature review

Background: Accessory spleens are congenital embryological aberrations usually found within the splenic hilum with no clinical significance. An Intra Pancreatic Accessory Spleen (IPAS) is an uncommon benign pancreatic lesion encountered clinically. The occurrence of an Epidermoid Cyst arising within an IPAS (ECIPAS) is exceedingly rare and is often misdiagnosed as a pancreatic pathology such as mucinous cystic neoplasm, cystic degeneration within a solid tumor such as a neuroendocrine tumor, or a lymph node. Case report: A 68-year-old male presented with intermittent post-prandial abdominal pain for over 2 years. Abdominal computer tomography identified a 5.2 cm calcified cyst within the pancreatic tail and a mucinous pancreatic neoplasm/pancreatic pseudocyst was considered in the differential diagnosis. The results of endoscopic ultrasound and fine needle aspiration were indeterminate. Due to persistent abdominal pain, the patient underwent a laparoscopic distal pancreatectomy with splenectomy. A gross examination of the distal pancreatic/splenectomy specimen confirmed a well-demarcated cystic lesion with brownish fluid within the pancreatic tail. Microscopic examination revealed a nonpathological pancreas separated by a fibrous capsule with a large cyst arising within an intrapancreatic accessory spleen. The cyst was lined with multilayered non-keratinized stratified squamous epithelium positive for pancytokeratin, CA 19-9, CK5/6, and p63 with no lymphocytic infiltrates and absent hair/ dermal appendages confirming an epidermoid cyst. CD8 outlined the dendritic network of the littoral cells of the splenic tissue in the cyst wall. Post-operative follow-up at 6 weeks was uneventful. Conclusion: The preoperative diagnosis of ECIPAS is extremely difficult as this entity shares overlapping radiological features with other cystic lesions such as mucinous pancreatic cysts. It is important for anatomic pathologists to recognize and consider the intrapancreatic compartment as a possible site for accessory spleen. As histopathology is the final determinant of this diagnosis, increased clinical awareness with an accurate diagnosis of this entity may prevent patients from unnecessary surveillance and/or extensive oncological-based surgical resection.

Adrenal Pseudocyst, Case Report

Pseudocyst type of adrenal cysts is most common; however, this type of ectopic cyst is quite rare in excessively large adrenal cysts. A35-year-old woman was admitted to our institution with distension of her right flank and the upper quadrant of her abdomen. Abdominal ultrasonography revealed a cystic lesion with a homogenous anechoic texture, and measuring 28 cm in diameter. Computed tomography imaging displayed a giant cystic lesion adjacent to the liver, pancreas, kidney. The origin of the cyst was not identified. We were not able to make a preoperative diagnosis; therefore, the patient underwent resection of the mass by open laparotomy for therapeutic diagnosis. Intraoperatively, the mass was identified to be cystic and adhered to the right adrenal gland. It was filled with more than 2500 mL of serous brown fluid. The content of the cyst contained no atypical cells on cytological examination, and the cyst was pathologically classified as a pseudocyst cyst. We describe a case of a patient with a giant pseudocyst of the adrenal gland. The present data suggest that surgeons should decide treatment strategy for large adrenal cysts in consideration of hormonal function, degree of size, and possibility of malignancy.

Holmium Laser Incision of Ejaculatory Duct (HoLIED): Surgical Procedure

Introduction: Ejaculatory duct obstruction is a well-known cause of infertility and many other symptoms, such as hematospermia and lower urinary tract symptoms. Diagnosis is made based on the medical history and a series of imaging tests identifying the obstructed ducts. Transurethral resection of the ejaculatory ducts is the mainstay treatment to release the obstruction. In this step-by-step surgical video, we will describe a novel technique using the holmium laser to incise the ejaculatory ducts in a patient with chronic lower urinary tract symptoms, hematospermia, and persistent urethral discharge. Materials and Methods: A pelvic MRI was obtained in workup of the above issues and identified a complex ejaculatory duct cyst. The patient consented for Holmium Laser Incision of Ejaculatory Duct. A holmium laser fiber was used through a 24F rigid cystoscope to unroof the ejaculatory duct cyst, resulting in the drainage of a dark brown fluid. Following unroofing of the cyst, the ejaculatory ducts were identified using a 17F rigid cystoscope and a 16F Foley catheter was inserted. Results: The Foley catheter was removed on POD1, and the patient was able to void. His symptoms improved progressively with time and antibiotics. A repeat MRI was obtained several months postoperatively and showed the resolution of the cystic lesion. Conclusion: Holmium Laser Incision of Ejaculatory Duct is safe and feasible procedure allowing to treat ejaculatory duct obstruction without increased risk of complications.

381 A Rare Case of CBD obstruction secondary to Endometriotric cyst

Abstract Background Bile flow obstruction due to bilary tree pathology is well documented. Intramural causes include gallstones and infections such as clonorchis sinensis and Ascaris Lumbriocodes1 mural causes include autoimmune diseases e.g Sclerosing cholangitis. Extrinsic compression are usually due to malignancy e.g Cholangiocarcinoma or pancreatic head carcinoma. we encountered a rare case of common bile duct (CBD) obstruction cause by large endometriotic cyst. Case report A fit & well, 85 year old female presented with gradual onset of Obstructive jaundice. admission Liver function tests indicated a Bilirubin of 485 subsequent Ct scan revealed a large endometriotic Cyst (15cm x10 cm) indenting the CBD and stomach. Endoscopic ultrasound confirmed the presence of a large cystic fluid collection. Patient`s biliary system was indirectly decompressed with AXIOSTM via gastric wall into cyst Copious dark brown non-viscous fluid was drained into stomach. Cytology results reported benign cyst contents without mucin or neoplastic epithelial cells. Fluids Amylase was 121 U/L. the patient recovered well, with resolution of Bilirubin. Discussion Endometriotic cyst have been reported to cause organ obstruction such as CBD and ureter1,2 patient's from previously reported cases had to endure major surgery to achieve symptomatic relief. AXIOSTM stent is a device commonly utilized for drainage of pancreatic pseudocyst and we report the use of it as a Novel and minimally invasive technique in this rare case of CBD obstruction.

PATHOLOGICAL ANATOMICAL CHANGES IN SAIGAS INFECTED WITH COENUROSIS CEREBRALIS

This article describes an autopsy of an animal infected with coenurosis, a parasitic disease caused by the larval stage of the tapeworm. A cadaver infected with cenosis showed moderate hardening, the abdomen was swollen and the eyes were closed. The spleen of all sick animals is softened and the tissue structure is disturbed. Examination of the subcutaneous fat showed signs of body fat, but they were mottled with red dots. The lymph nodes were also swollen, dark red, moist, mottled with tiny red dots, with red fluid running along the surface. The lungs were enlarged, the consistency was loose, the serous membrane had many dark red dots, and bloody fluid was leaking from the surface. The heart was found to be loose, enlarged, with soft consistency. The liver was whole-blooded, enlarged, with many dark red dots on the surface, and the gallbladder was moderately full, without stones or parasites.
 On examination of the digestive tract we saw that the stomach was swollen due to a brown fluid content, the intestinal mucosa was damaged and swollen due to the fluid content within, and the intestinal mucosa was swollen, dark red and thickened in places. The brain tissue is hyperemic and oncospheres are found in tubes twisted across the surface and depth of the brain. In the early stages of cenurotic disease, newly formed haemorrhages and hyperaemia were observed in some parts of the cerebral membranes. A detailed description of the pathological anatomical changes that occurred as a result of the disease is given in the article

Massive pleural effusion post-emergency cesarean in undiagnosed congenital diaphragmatic hernia

Introduction: Bochdalek’s hernia is a congenital diaphragmatic hernia (CDH) resulting from inadequate closure of the membrane over the left side of the hemidiaphragm. Patients will start to develop symptoms upon displacement of abdominal contents into the thoracic cavity. This case report highlights the radiological modality findings that can be used in diagnosing a late-presentation CDH in adults. Case Report: A 35-year-old postpartum woman developed shortness of breath, left-sided chest pain, episodes of vomiting and epigastric tenderness within 24 hours post-emergency cesarean section. An initial diagnosis of left tension hydrothorax was made based on the clinical and radiological findings. Left diagnostic and therapeutic thoracocentesis using landmark technique was performed and brownish fluid was obtained upon aspiration. Post-procedural chest X-ray (CXR) reported cystic-like features over the left hemithorax. Therefore, computed tomography (CT) thorax was proceeded and confirmed the left diaphragmatic hernia with a mediastinal shift to the right. However, the patient’s condition worsened and required emergency open thoracotomy with left diaphragmatic hernia repair. Intraoperative findings showed left Bochdalek’s hernia complicated by multiple visceral organ perforations secondary to previous thoracocentesis. The patient was discharged well after a few weeks of hospital stays. Conclusion: The diagnosis of late-presentation Bochdalek’s diaphragmatic hernia remained challenging and can be easily missed. Therefore, a comprehensive evaluation is required prior to performing an invasive diagnostic procedure. Chest X-ray and ultrasound are useful diagnostic aid in the absence of CT thorax and magnetic resonance imaging (MRI) modalities.

Congenital glioblastoma – prenatal diagnosis becoming a diagnostic challenge after birth: a case report

Abstract Objectives The incidence of congenital brain tumors is estimated at 1.1–3.6 per 100.000 live births, accounting for 0.5–2 % of all cancers in the pediatric population. Congenital gliomas account for 3.1–8.9 % of all congenital brain tumors and are cancers with a poor prognosis. The rate of stillbirth and death on the first day of life reaches 29 %; 38 % die within the first week, and 56 % die within the first two months. The average length of survival is two years. Case presentation In the 29th week of pregnancy, a female fetus was diagnosed with intracranial hemorrhage complicated by hydrocephalus. Postnatal brain MRI imaging showed a solid proliferative lesion of the left hemisphere with dilatation of the ventricular system. Brown cerebrospinal fluid was collected during the puncture of the left lateral ventricle to reduce hydrocephalus. No tumor cells were detected by cytology. Due to increasing hydrocephalus, the patient was qualified for Rickham reservoir implantation. On day 27th, a craniotomy was performed to determine the etiology of recurrent prenatal intraventricular bleeding. During surgery, the bleeding mass raised the suspicion of neoplasm—histopathological examination of the retrieved tissue diagnosed WHO stage IV malignant glioma. The patient died at 8 months of age. Conclusions Prenatal diagnosis of an abnormal structure in the fetal brain remains a diagnostic challenge in neonates. Glioblastoma is a rare neoplasm with a poor prognosis.

Радионуклидная диагностика в определении сопутствующей патологии у онкологических больных

The aim of this study is to demonstrate the significance and necessity of radionuclide diagnostics of oncologic pathology of different nature on the instance of a clinical case of detection of multiple foci of secondary nature (mts) of parathyroid gland tumor by skeletal bone scintigraphy in the course of routine examination of a patient for breast cancer. The data from the medical records, protocols and radiation methods of examination of the patient were used as the study material. During a routine examination for metastases of breast cancer through radionuclide examination of the parathyroid glands and scintigraphic examination of the skeletal bones, pathologic foci of radiopharmaceutical (RP) hyperfixation were detected in the patient. On further computed tomography (CT) of the knee joints it was found that the picture may correspond to multiple secondary lesions of the skeletal bones on the background of parathyroid gland disease. After a week the patient underwent a biphasic radionuclide study of the parathyroid glands, which made it possible to assess the presence of obvious scintigraphic signs of hyperfunctioning adenoma of the left lower parathyroid gland. Further, a thyroid gland (TG) tissue biopsy study was performed, which showed that the tissue fragment on the section was light brown with the presence of a cyst filled with brown fluid, which may correspond to a brown tumor. Thus, a patient with main breast disease is likely to be diagnosed with other unrelated cancers. The key diagnostic method in this case will be a scintigraphic study with single photon emission computed tomography (SPECT), which provides the most accurate visualization of pathology, its description and prediction of further therapy both in outpatient and inpatient settings. For the majority of cancer patients it is advisable to conduct regular examination with the help of scintigraphy for the purpose of prevention and early detection of concomitant pathology.

Symptoms: Purple Ear Drum and Hearing Loss

Symptoms: Purple Ear Drum and Hearing Loss

Two Methods for Adenomyotic Cyst Excision

<h3>Study Objective</h3> The objective of this video is to demonstrate two techniques for hysteroscopic resection of adenomyotic cysts. <h3>Design</h3> N/A. <h3>Setting</h3> A patient desiring fertility presents for further evaluation. Imaging is notable for two fundal cysts on ultrasound consistent with adenomyosis. After informed consent is obtained, OR hysteroscopy is performed under ultrasound guidance. <h3>Patients or Participants</h3> One patient with adenomyotic cysts is highlighted. <h3>Interventions</h3> The patient is taken to the operating room and a 5.5mm rigid hysteroscope is advanced to the fundus under ultrasound guidance. After confirming the location of adenomyotic cysts via ultrasound, hysteroscopic scissors are used to open the cysts, with adenomyosis confirmed by release of chocolate brown fluid. Cyst walls are resected in their entirety, one sharply and one with bipolar loop. <h3>Measurements and Main Results</h3> Direct visualization of the endometrial cavity as well as intraoperative ultrasound confirm complete removal of adenomyotic cysts. Pathology of the cyst walls confirmed adenomyosis. <h3>Conclusion</h3> Hysteroscopic resection of adenomyosis is safe and effective in select patients with focal disease, allowing for targeted removal under direct visualization. Here we demonstrate two hysteroscopic techniques for resection of adenomyotic cyst wall: sharp dissection, and the bipolar loop electrode.

The Role of Heterogeneity on Deformation and Flow in Fractured Coal Slopes

The fractures in brown coal influence fluid flow and deformation in these materials. These fractures display highly heterogeneous characteristics in the distributions of their apertures, separations and orientations. While discrete fracture models have previously been used to analyse the effects of fractures, such models are not feasible for the scales encountered in many brown-coal mines. Instead, here a continuum permeability model is used to capture the effects of the fracture heterogeneity on fractured coal. This paper presents an analysis of the fracture heterogeneity of brown coal at the AGL Loy Yang coal mine in Latrobe Valley and its influence on the fluid flow, dispersion and rock stability. A stress dependent fracture permeability is considered and captures the effects of heterogeneity in the fracture aperture and orientation. Numerical simulations conducted with multiple plasticity models present different flow paths and potential failure modes depending on the the implemented boundary conditions.

S3285 A Rare Case of Pyogenic Liver Abscess Caused by Raoultella ornithinolytica

Introduction: Patients with a history of splenectomy have a higher prevalence of infections with encapsulated organisms due to decreased phagocytic activity and humoral response. One such rare organism is Raoultella ornithinolytica, a Gram-negative bacillus commonly found in the aquatic environment. Here we present a rare case of this bacterium causing liver abscess. Case Description/Methods: A 72-year-old female with a history of hypertension, hyperlipidemia, and splenectomy (secondary to abdominal trauma) presented after being found down. She complained of a recent history of diarrhea 2 days ago. Blood pressure was 80/60 mmHg and temperature was 101 degrees F at presentation. She was found to have elevated liver enzymes and Klebsiella oxytoca bacteremia (found on Verigene multiplex PCR testing) and was started on broad-spectrum antibiotics. CT of the abdomen in the emergency room revealed a 3x2x5 cm hypodense lesion in the left lobe of the liver. She underwent ultrasound-guided removal of 35 cc dark brown colored fluid, which was positive by culture for Raoultella ornithinolytica. Her antibiotics were narrowed to cefazolin, and the infection was thought to be related to recent diarrhea (of unknown etiology) resulting in intestinal mucosal damage leading to translocation of the bacterium across the intestinal wall into the liver. Of note, on high specificity microbiological testing using matrix assisted desorption-time of flight (MALDI-Tof) technology, the organism recovered from the blood was confirmed to be Raoultella ornithinolytica. Discussion: Incidence of Raoultella ornithinolytica infection has been on the rise in the past decade, and our patient is the second reported case of Raoultella ornithinolytica liver abscess. In humans, it usually causes skin flushing, vomiting, diarrhea, and headache. While the first case, as reported by Surani et al in 2020, had a long-standing liver cyst that was thought to be infected with Raoultella ornithinolytica, our patient did not have any nidus in the liver that could harbor this bacterium. However, she had a history of splenectomy, possibly putting her at higher risk of infection with encapsulated bacteria. In addition, Raoultella ornithinolytica is closely related to Klebsiella oxytoca, but is not recognized in the multiplex PCR database which accounts for the discrepancy in initial identification as seen in our case. Our case adds to the growing literature regarding Raoultella ornithinolytica as an increasing virulent pathogen in humans.

S2836 Gastrohepatic Ligament Bronchogenic Cyst Diagnosed by EUS FNA

Introduction: Bronchogenic cysts pose diagnostic and therapeutic challenges due to its varied locations and presentations. Case Description/Methods: 58-year-old woman presented with two weeks of epigastric and RUQ abdominal pain. Presenting labs: TB 4.3 mg/dL, DB 3.4 mg/dL, AP 328 U/L, AST 1,265 U/L, ALT 1,890 U/L. Workup was negative for pancreatitis, acute hepatitis, and acetaminophen toxicity. CT scan showed biliary duct dilatation with a 5mm stone in the common bile duct, and a 3.5 x 3.6 cm thick-walled mass with rim enhancement and hypodense central component within the gastrohepatic ligament (GHL) (A). EUS characterized the mass as a hypoechoic cystic lesion with a concentric 4mm thick wall (B). Fine needle aspiration (FNA) of the cyst produced 14ml of brown and viscous fluid. After cyst aspirate, FNA of the decompressed cyst wall was also performed. Cyst fluid amylase was < 3 U/L, CEA was 157 ng/mL, and cytology was negative for malignancy. Cytology of the cyst wall showed benign ciliated columnar epithelial cells consistent with a bronchogenic cyst (C). ERCP was performed during EUS for stone extraction. She then underwent cholecystectomy with improvement of symptoms and liver enzymes. Her asymptomatic bronchogenic cyst is undergoing active surveillance. (Figure) Discussion: Bronchogenic cysts are foregut-derived malformations of the respiratory tract and while relatively rare, is the most common primary cyst of the mediastinum accounting for 6-15% of primary mediastinal masses. The location depends on the embryological stage of development when the anomaly occurs. Most are in the mediastinum and uncommonly in the lung parenchyma, esophagus, heart, subdiaphragm, and retroperitoneum. Only one other case has been reported of a bronchogenic cyst in the GHL. Reported prevalence is 1:42,000-68,000 admissions in two hospital series. Some present with symptoms such as cough, fever, pain, and dyspnea. Complications can arise with compression of mediastinal structures, recurrent infection, hemorrhage, rupture, and malignant degeneration. Others are asymptomatic and incidentally found on chest radiograph or cross-sectional imaging. No standard exists for treatment. Traditionally, patients underwent surgical excision for definitive diagnosis and management. EUS FNA serves as a less invasive method for diagnosis. Controversy still exists regarding management of asymptomatic cysts with several reports advocating for complete removal due to likelihood of development of symptoms and potential for serious illness.Figure 1.: CT, EUS, Cytology.

Gastric Adenocarcinoma of the Remnant Stomach Presenting With a Cystic Intra-abdominal Mass 11 Years After Roux-en-Y Gastric Bypass.

CASE REPORT Morbid obesity defined as a body mass index of ≥ 40 kg/m2 is associated with increased morbidity and all-cause mortality.1 Roux-en-Y gastric bypass (RYGB) is the desired surgical intervention because of its proven benefits.1,2 Morbid obesity is associated with increased risk of gastric cancer; however, the altered anatomy of the stomach after bypass is challenging for ongoing surveillance of the remnant stomach.2 To date, only 17 cases of gastric remnant malignancy after RYGB are reported.2 We present a rare case of gastric remnant adenocarcinoma 11 years after RYGB presenting with abdominal pain and weight loss due to a large intra-abdominal cystic mass abutting the gastric remnant. Abdominal computed tomography without contrast revealed a large cystic structure abutting the stomach and pancreas (Figure 1). An esophagogastroduodenoscopy was normal. An endoscopic ultrasound (EUS) revealed a single round anechoic lesion >100 mm in size in the peripancreatic and perigastric peritoneal space (Figure 2). Typical mucosal, submucosal, and muscular propria layers were noted within the wall of the cystic structure without communication to the excluded stomach (Figure 3). Fine-needle aspiration of fluid (Expect 19 Gauge Flex Needle [Boston Scientific, Marlborough, MA]) demonstrated 750 mL of brown fluid with unremarkable cytology and normal lipase and amylase levels. The carcinoembryonic antigen (CEA) level in the cystic fluid was markedly elevated at 2,358 ng/mL when compared with serum CEA of 76.6 ng/mL.Figure 1.: Axial images of the abdomen and pelvis show the cystic dilation.Figure 2.: The cystic structure seen before fine-needle aspiration (FNA) (thick arrow).Figure 3.: Endoscopic ultrasound (EUS) images revealing the wall layers of the cystic structure (thick arrow) is seen after cyst fluid fine-needle aspiration (FNA), which demonstrates that it is not a cyst but a gastrointestinal structure.A second EUS performed because of recurrent abdominal distension showed a persistent cystic structure. Injection of contrast within the cystic structure demonstrated communication between the cyst and the excluded stomach. Fine-needle biopsy (Acquire 25 Gauge Needle [Boston Scientific]) of an area of the thickened gastric wall demonstrated poorly differentiated adenocarcinoma (Figure 4).Figure 4.: The area of the excluded stomach (thick arrow) with abnormal thickening of the stomach wall was biopsied revealing adenocarcinoma.Diagnosis of gastric remnant malignancy is usually confirmed at a median of 9 years after RYGB (range is 1–22 years) with abdominal computed tomography scans.2 EUS and transgastric endoscopy may be considered as alternatives to double-balloon enteroscopy for tissue biopsy in the setting of technically difficult access of the gastric remnant.3,4 Prevention and surveillance methods including remnant gastrectomy proposed in regions with a high prevalence of gastric cancer remain controversial and not well established. More studies are needed to determine whether CEA can be considered for screening of the cancer in the excluded stomach in patients with a history of morbid obesity and RYGB.5 DISCLOSURES Author contributions: GW Khneizer and BL Bick conceived and drafted the work. N. Mahendraker designed and critically revised the work, and all authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work. GW Khneizer is the article guarantor. Financial disclosure: None to report. Informed consent could not be obtained from the family of the deceased. All identifying information has been removed from this case report to protect patient privacy.

SUCCESSFUL TREATMENT OF ASPERGILLUS-INFECTED MALIGNANT PLEURAL EFFUSION

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Fungal pleural infections are difficult to treat especially when lung is trapped secondary to malignancy. CASE PRESENTATION: 65-year-old male underwent unsuccessful talc pleurodesis for malignant effusion. The patient presented 6 weeks later with severe cough, fatigue, and mild neutropenia. Recurrent effusion was noted and brown fluid aspirated with immediate relief and patient was started on antimicrobials. Cultures grew Streptococcus mitis and Aspergillus species. Patient was admitted and treated with IV antibiotics and PO voriconazole. One week later, he underwent exploration: lung was partly trapped; surfaces were covered by white debris, which was scraped off and pleural space washed out with water and filled with Amphotericin B solution (100mg/1L). After 30 minutes, a tunneled pleural catheter (TPC) was placed. TPC was drained 48h later and continued with every-other-day drainage. Amoxicillin/clavulanate + voriconazole PO continued for 5 weeks. Every other week pleural fluid cultures were obtained and were negative. TPC stopped draining 3 months later and was removed. Currently, the patient has no evidence of malignancy recurrence by PET. Imaging demonstrates trapped lung. DISCUSSION: In this situation, intraoperative washout and intrapleural Amphotericin B instillation were done to help sterilize pleural space in the setting of trapped lung. TPC allowed frequent drainage of pleural space as the infection can be managed successfully in 72% of patients without TPC removal. As prolonged drainage was anticipated, TPC was thought to be more comfortable than a larger bore chest tube/collection system. CONCLUSIONS: Intrapleural antifungal therapy can effectively sterilize pleural space and TPC can be used when repeat administration is anticipated. DISCLOSURE: Nothing to declare. KEYWORD: Aspergillus, tunneled pleural catheter

A bizarre surgical aftermath of caesarean scar endometriosis

A 32-year-old multiparous female patient came to our gynaecology OPD with complaints of a painful lump over the previous caesarean scar. She had a history of two caesarean sections previously in 2012 &amp; 2015. The last Caesarean section was done electively along with copper T insertion in 2015. In the postoperative period, she had a superficial surgical site infection which was managed successfully with antibiotics and re-suturing done on day 8 postoperative period and rest were uneventful. On per abdominal examination seen, a hyperpigmented hard indurated tender mass of 6*4cm present in the right side of scar site with 2mm orifice and chocolate brown fluid seen oozing from the orifice on pressing. Ultrasound showed a hypoechoic mass of 4*6 cm in the subcutaneous plan of the abdominal wall extending up to the anterior uterine wall with minimal vascularity. Possibility of scar endometriosis was given. Contrast-enhanced computed tomography showed defined Solid soft tissue mass of size 2*8.3*3.4 cm (CC*AP*TR) seen in the deep subcutaneous plan of the anterior abdominal wall in the hypogastric region extending to deep musculature of rectus abdominis. Rectus muscle and anterior rectus sheath closed with loop ethilon and 15*15cm trulene mesh placed as only mesh fixed with 2-0 prolene and another drain placed. The patient made a good recovery following the surgery. Histopathology report consistent with scar endometriosis showing foci of endometrial tissues consisting of cystic endometrial glands surrounded by endometrial stroma.

Paediatric traumatic chronic subdural hematoma - a very rare entity

Objectives: To study the prevalence of Traumatic chronic subdural hematoma in children.&#x0D; Material and methods: This is a prospective study conducted at a tertiary care centre at Gwalior, from November 2020 to November 2021. We encountered 5 patients admitted for signs of raised intracranial tension due to Head trauma, showing Chronic subdural Haematoma ( CSDH) in plain CT Head or MRI brain. All patients had no history of loss of consciousness, no history of vomiting, no history of seizures, no history of nasal or ear bleed and GCS was 15/15. All blood investigation and coagulation profiles are normal. Frontal and parietal 2.5 cm trephine craniotomy with evacuation of subdural hematoma was done. Patients were followed up at 1 month and 6 months&#x0D; Result: All children are male. Age ranging from 7 years to 14 years, Mean age of presentation was 10 years. All patients had a history of head trauma and mode of injury road traffic accidents (RTA) and Glasgow coma scale(GCS) at admission was 15 and duration of developed CSDH was 20 days to 42 days’(mean30.40 days). All patients had good outcomes and the average follow-up was 6.5 months. All patients went on Surgical intervention. and outcome assessed by Glasgow Outcome score. 3 out of 5 patients had brownish fluid as a collection in subdural space while the other 2 patients had fluid that has motor oil like consistency in subdural space. All the patients were subjected to a similar procedure. The postoperative course was uneventful. Mean hospital stay was 7 days. A postoperative scan was done on the 7th day.&#x0D; Conclusion: Chronic Subdural Hematoma is a disease reported in infants and the elderly population. It is uncommon in the age group of 2-14 years. Most of the children present with symptoms of raised intracranial tension due to head injury, with no reported history of repeated head trauma, child abuse &amp; coagulopathy. Traumatic Chronic subdural collection should be considered as one of the diagnoses as the prognosis of this disease is better. However, due to the scarcity of reports in the literature, established guidelines are not available.