Inflammatory Mass Research Articles

This issue of ACTA

This issue of ACTA

English

BACKGROUND There is a wide range of adnexal masses ranging from functional cyst to infection and even malignancy. Epithelial ovarian tumours are the most common benign ovarian lesion. The purpose of this study was to study the pattern of adnexal masses in rural area and plan the preventive steps according to the pattern. METHODS It was a retrospective study of patients who presented with adnexal masses in Bhagat Phool Singh Medical College (Women), Khanpur, Sonepat, Haryana, India over a period of 5.5 years from September 2012 to August 2018. The file records of the patients who underwent surgery for adnexal masse were evaluated to identify the risk factors, presenting complaints, examination findings, serological markers and radiological findings. The histopathological reports were reviewed. The cases excluded were ectopic pregnancies. Frequency distribution tables were used and data was analyzed using percentages. RESULTS Out of total 180 adnexal masses, 167 (92.77 %) cases were of ovarian origin. Out of these, 150 (83.33 %) cases were benign and 17 (9.44 %) were malignant. Among the benign lesions, serous cystadenoma was the most common lesion counting for 54 cases i.e., 30 %. In our study, most common symptom was vague abdominal pain- 63.88 %. Maximum adnexal masses were in the age group of 41 - 50 years i.e., 53 (29.44 %). Different types of surgeries were done. Maximum were bilateral oophorectomies with transabdominal hysterctomy 88 (48.88 %). CONCLUSIONS By proper education about personal and perineal hygiene, use of contraceptives, we can at least prevent some sexually transmitted diseases causing pelvic inflammatory disease (PID) and adnexal masses. KEYWORDS Adnexal Mass, Benign, Malignant, Serous Cystadenoma

Cholangioscopy in primary sclerosing cholangitis: a case series of benign features.

Background and AimsCholangioscopy is useful in establishing a visual diagnosis of cholangiocarcinoma (CCA), but this is harder to achieve in primary sclerosing cholangitis (PSC) because of the stricture-forming nature of the disease. Furthermore, it can be harder to differentiate malignant from benign features of the underlying inflammation. This case series demonstrates the varied features of nonmalignant inflammatory findings in PSC.MethodsA single experienced endoscopist performed cholangioscopy for PSC cases referred for ERCP.ResultsCholangioscopy in these 5 cases without CCA demonstrated the features of acute and chronic inflammation, acute inflammatory mass, dominant stricture, acute cholangitis in a duct with features of chronic inflammation with a large pigmented stone, and fibrostenotic disease. Cholangioscopic maneuvers such as advancement across strictures after balloon dilation, targeted mucosal biopsy, and electrohydraulic lithotripsy (EHL) of impacted stones are demonstrated. The relevant radiographic and histopathologic features of the disease accompany each case description. Regarding long-term prognosis, 1 case of acute inflammatory mass and a case of worsening liver function required a liver transplant evaluation, whereas the other 3 cases remain stable.ConclusionsCholangioscopic features of benign disease in PSC are varied. Knowledge of these features is essential in differentiating between benign and malignant findings. These features, combined with biopsy and cytology evaluation, can help in tailoring management in patients with benign PSC.

Treatment Modality of Idiopathic Granulomatous Mastitis with Surgery Alone or in Combination with Steroid

Background: Idiopathic Granulomatous Mastitis (IGM) is a rare chronic inflammatory disease. Diagnosis and treatment is still a challenge because of obscure etiology and rareness. Owing to wide spectrum of IGM it is difficult to standardize and optimize the treatment. The aim of our study was to evaluate the outcome of surgical excision or in combination with steroid in treating IGM.
 Methodology: A randomized controlled clinical trial was done in BIRDEM (Bangladesh Institute of Research and Rehabilitation of Diabetic, Endocrine and Metabolic Disorder) Hospital, Dhaka, Bangladesh from July’2008 to June’2018. Overall 82 patients met the inclusion criteria. We analyzed therapeutic modalities and compared the patients’ outcomes based on treatment.
 Results: All patients underwent wide excision with clear margin under general anesthesia. Post operatively steroid was given in 41 patients. Duration of steroid therapy was 6 months after surgery. We have seen that recovery time was short in steroid group (Gr-II) average 167.07 days in compared without steroid (Gr l) average 253.28 days. Patients who underwent surgery only (GR-I) about 49.90% patients experienced recurrence (e.g. fistula formation and inflammatory mass etc.) On the other hand, 12.1% patients developed recurrences that were treated with steroid following surgery (Gr-II).
 Conclusion: Surgery with steroid is more effective in treatment of idiopathic granulomatous mastitis than surgery alone.
 Bioresearch Commu. 7(1): 924-926, 2021 (January)

Symptomatic Heterotopic Gastric Mucosa in Distal Esophagus

Abstract Introduction Heterotopic gastric mucosa (HGM) in esophagus is commonly noted as an inlet patch at endoscopy. We describe a rare patient with symptomatic distal esophageal HGM. Case Report A 40-year-old male presented with retrosternal pain and marked odynophagia for the last 4 weeks without any history of ingestion of antibiotics, foreign body, or corrosive. Endoscopy showed abrupt circumferential transition to salmon pink mucosa at 35 cm from incisors. From 35 to 41 cm, there were areas of polypoid edematous thickening with few superficial ulcers of 1 to 3 mm. Squamous epithelium was visualized at narrow band imaging from 41 cm to the Z-line at 43 cm with no hiatus hernia. Biopsy showed gastric-type mucosa with parietal cells without dysplasia. Serology for cytomegalovirus and human immunodeficiency virus was negative. He was managed with proton pump inhibitors (PPIs) and prokinetics and improved symptomatically. Follow-up endoscopy at 3 months demonstrated healing of ulcers with persistence of HGM and pseudopolyps. He remains well on maintenance with PPI at 1-year follow-up. Conclusion Symptomatic HGM in distal esophagus is rare and can be differentiated from Barrett’s esophagus histologically and by presence of squamous epithelium between HGM and stomach. Inflammatory mass lesions may develop and mimic esophageal malignancy. Symptoms are largely due to acid production and usually respond to PPI.

Nonspecific orbital inflammation and thyroid eye disease, a rare comorbidity: report of two cases and review of literature

BackgroundTo present the very rare comorbidity of developing non-specific orbital inflammation (NSOI) in two patients with histories of definite thyroid eye disease (TED).Case presentationBoth patients complained of new-onset progressive proptosis although their thyroid disease was controlled and computed tomography scan revealed an intraorbital inflammatory mass. The pathological assessment indicated that both patients had developed fibrosing NSOI. Therefore, intravenous corticosteroids were administered. The mass regressed and the amount of proptosis was decreased in both patients.ConclusionsWe reviewed all related cases in the literature and extracted their clinical and radiological characteristics for this paper. Ophthalmologists should consider TED and NSOI in patients with a new-onset complaint of proptosis. Despite rare comorbidity of TED and NSOI, it should be considered especially in patients with refractory proptosis, and lead to its further evaluation and prompt management.

MRI characteristics of intracranial masses in the paediatric population of KwaZulu-Natal: A neuroimaging-based study.

BackgroundMRI is the imaging modality of choice for the assessment of intracranial masses in children. Imaging is vital in planning further management.ObjectivesThe purpose of this study was to describe the common intracranial masses and their imaging characteristics in the paediatric population referred to Inkosi Albert Luthuli Central Hospital for MRI of the brain.MethodWe retrospectively reviewed the medical records of paediatric patients (aged from birth to 18 years) who underwent MRI investigations for intracranial masses between January 2010 and December 2016.ResultsA total of 931 MRI brain scans were performed. One hundred and seven scans met the inclusion criteria, of which 92 were primary brain tumours and 15 were inflammatory masses. The majority were females (56%). The mean age was 12 ± 4.52 (range of 3–18 years). The most common presenting symptom was seizures (70/107, 65.4%). We categorised the masses according to supra- and infratentorial compartments. The most common site for masses was the supratentorial compartment (n = 56, 52%). The most common masses in the supratentorial compartment were craniopharyngiomas (14/45, 31.1%), whilst in the infratentorial compartment, the most common masses were medulloblastomas (24/47, 51.1%).ConclusionIn our series, the supratentorial compartment was the commonest site for intracranial masses. The most common tumour in the infratentorial compartment was medulloblastoma. This information is vital in formulating differential diagnoses of intracranial masses.

Application of ultrasound and contrast-enhanced ultrasound to distinguish salivary focal inflammatory masses from malignant masses: A retrospective observational study.

The aim was to retrospectively analyze the ultrasonographic and clinical characteristics of focal inflammatory masses and malignant masses of salivary gland by using B-mode ultrasound (US) and contrast-enhanced ultrasound (CEUS) for differential analysis. The features of US and CEUS were retrospectively analyzed for 19 cases of focal salivary inflammatory masses and 45 cases of malignant salivary masses. All cases were confirmed by pathohistological examination. On B-mode US, the incidence of expansive growth patterns of malignant salivary masses (44.4%, 20/45) was significantly higher than that of focal salivary inflammatory masses (15.8%, 3/19) (p = 0.029). The rate of lymphadenopathy surrounding salivary glands of malignant salivary masses (42.2%, 19/45) was significantly higher than that of focal salivary inflammatory masses (15.8%, 3/19) (p = 0.042). On CEUS, clear enhancement margins were more common in malignant salivary masses (44.4%, 20/45) compared to focal salivary inflammatory masses (15.8%, 3/19) (p = 0.029); Rapid washout was more common in malignant salivary masses (82.2%, 37/45) than focal salivary inflammatory masses (31.6%, 6/19) (p < 0.001). Rapid washout on CEUS and craniocaudal diameter were independent predictive factors in differentiating salivary inflammatory masses and malignant masses according to binary logistic regression analysis. US and CEUS achieved a sensitivity of 80.0%, a specificity of 78.9% and an accuracy of 80.0% for discrimination between salivary inflammatory masses and malignant masses. Therefore, a multimodal ultrasonographic pathway combining clinical manifestations, B-mode US and CEUS was needed to differentiate between salivary focal inflammatory masses and malignancies to avoid unnecessary biopsies.

355 Incomplete Intestinal Rotation with Appendicular Abscess Causing Diagnostic Dilemma in An Adult Patient

Abstract Intestinal malrotation presents as an emergency in the neonate and within the first year of life. Incomplete intestinal rotation may remain asymptomatic and undiagnosed. Adult patients are usually diagnosed incidentally while being investigated for nonspecific abdominal symptoms. We report a case of a 43-year-old female who presented with a 10-day history of paraumbilical abdominal pain. Computed tomography demonstrated features of incomplete intestinal rotation and a centrally located inflammatory mass related to the appendix. She underwent a laparotomy and appendectomy. Upon a brief literature review of similar cases, there seems to be a conflict of views regarding the management of incidentally diagnosed adult incomplete intestinal rotation.

A case report of portal vein thrombosis and common bile duct compression in the patient having pseudocyst of pancreas and its management by percutaneous trans-hepatic biliary drainage

Pancreatitis is a systemic disease owing to release of inflammatory mediators and digestive enzymes. Acute pancreatitis is sudden inflammation of the pancreas. Alcohol and gallstones are main cause of acute pancreatitis. Chronic pancreatitis is the persistent inflammation and irreversible fibrosis associated with atrophy of pancreatic parenchyma. There are various complications associated with pancreatitis such as strictures, pancreatic necrosis, pseudo-cyst of pancreas, pancreato-cutaneous fistulas, venous thrombosis, arterial aneurysm in various arteries around pancreas etc. Common bile duct (CBD) strictures are a common complication in patients with advanced chronic pancreatitis and have a variable clinical presentation ranging from an incidental finding to overt jaundice and cholangitis. CBD strictures occur as a consequence of recurrent acute inflammatory episodes which may ultimately result in a periductal fibrotic stricture. CBD can be compressed as a result of extrinsic compression by large pseudocyst or aneurysm. The diagnosis is mostly made during investigations for abdominal pain but jaundice may be the initial clinical presentation. The jaundice is typically transient but may be recurrent with a small risk of secondary biliary cirrhosis in longstanding cases. Vascular complications in chronic pancreatitis are rare. Venous thrombosis is the most common complication of pancreatitis affecting venous system. It occurs as consequences of an inflammatory mass in head of pancreas, and splenic vein thrombosis occurs in association with chronic pancreatitis in 4-8% cases. Present case is a case of acute pancreatic collection in head of pancreas with aneurysmal small bleeding causing complete CBD compression and extensive venous thrombosis involving superior mesenteric vein, portal vein, splenic.

A radiomic-based model of different contrast-enhanced CT phase for differentiate intrahepatic cholangiocarcinoma from inflammatory mass with hepatolithiasis.

Intrahepatic cholangiocarcinoma (ICC) is hard to distinguish from inflammatory mass (IM) complicated with hepatolithiasis in clinical practice preoperatively. This study looked to develop and confirm the radiomics models to make a distinction between ICC with hepatolithiasis from IM and to compare the results of different contrast-enhanced computed tomography (CT) phase. The models were developed in a training cohort of 110 patients from January 2005 to June 2020. Radiomics features were extracted from both arterial phase and portal venous phase contrast-enhanced computed tomography (CT) scans. The radiomics scores based on radiomics features, were built by logistic regression after using the least absolute shrinkage and selection operator (LASSO) method. The rad-scores of two contrast -enhanced CT phases and clinical features were incorporated into a novel model. The performance of the models were determined by theirs discrimination, calibration, and clinical usefulness. The models were externally validated in 35 consecutive patients. The radiomics signature comprised two features in arterial phase (training cohort, AUC = 0.809, sensitivity 0.700, specificity 0.848, and accuracy 0.774;validation cohort, AUC = 0.790, sensitivity 0.714, specificity 0.800, and accuracy 0.757) and three related features in portal venous phase (training cohort, AUC = 0.801, sensitivity 0.800, specificity 0.717, and accuracy 0.759; validation cohort, AUC = 0.830, sensitivity 0.700, specificity 0.750, and accuracy 0.775) showed significant association with ICC in both cohorts (P < 0.05).We also developed a model only based on clinical variables (training cohort, AUC = 0.778, sensitivity 0.567, specificity 0.891, and accuracy 0.729; validation cohort, AUC = 0.788, sensitivity 0.571, specificity 0.950, and accuracy 0.761). The radiomics-based model contained rad-score of two phases and two clinical factors (CEA and CA19-9) showed the best performance (training cohort, AUC = 0.864, sensitivity 0.867, specificity 0.804, and accuracy 0.836; validation cohort, AUC = 0.843, sensitivity 0.643, specificity 0.980, and accuracy 0.821). Our radiomics-based models provided a diagnostic tool for differentiate intrahepatic cholangiocarcinoma (ICC) from inflammatory mass (IM) with hepatolithiasis both in arterial phase and portal venous phase. To go a step further, the diagnostic accuracy will improved by a clinico-radiologic model.

Management of breast infections in primary care

Breast infections are a common presentation globally. Symptoms can range from mild discomfort and erythema of the skin to systemic sepsis and abscess formation with associated long-term physical and psychological morbidity. Although more common in the puerperium, non-lactating women, in particular, those between the ages of 18 and 50 years can be affected by the condition. Prompt recognition and treatment in primary care can reduce the incidence of abscess formation. Delayed or inappropriate treatment can lead to chronic infection with associated tissue destruction. In a minority of cases an inflammatory mass and skin changes can be a presenting feature of breast cancer.

Deep learning applied to two-dimensional color Doppler flow imaging ultrasound images significantly improves diagnostic performance in the classification of breast masses: a multicenter study.

BackgroundThe current deep learning diagnosis of breast masses is mainly reflected by the diagnosis of benign and malignant lesions. In China, breast masses are divided into four categories according to the treatment method: inflammatory masses, adenosis, benign tumors, and malignant tumors. These categorizations are important for guiding clinical treatment. In this study, we aimed to develop a convolutional neural network (CNN) for classification of these four breast mass types using ultrasound (US) images.MethodsTaking breast biopsy or pathological examinations as the reference standard, CNNs were used to establish models for the four-way classification of 3623 breast cancer patients from 13 centers. The patients were randomly divided into training and test groups (n = 1810 vs. n = 1813). Separate models were created for two-dimensional (2D) images only, 2D and color Doppler flow imaging (2D-CDFI), and 2D-CDFI and pulsed wave Doppler (2D-CDFI-PW) images. The performance of these three models was compared using sensitivity, specificity, area under receiver operating characteristic curve (AUC), positive (PPV) and negative predictive values (NPV), positive (LR+) and negative likelihood ratios (LR−), and the performance of the 2D model was further compared between masses of different sizes with above statistical indicators, between images from different hospitals with AUC, and with the performance of 37 radiologists.ResultsThe accuracies of the 2D, 2D-CDFI, and 2D-CDFI-PW models on the test set were 87.9%, 89.2%, and 88.7%, respectively. The AUCs for classification of benign tumors, malignant tumors, inflammatory masses, and adenosis were 0.90, 0.91, 0.90, and 0.89, respectively (95% confidence intervals [CIs], 0.87–0.91, 0.89–0.92, 0.87–0.91, and 0.86–0.90). The 2D-CDFI model showed better accuracy (89.2%) on the test set than the 2D (87.9%) and 2D-CDFI-PW (88.7%) models. The 2D model showed accuracy of 81.7% on breast masses ≤1 cm and 82.3% on breast masses >1 cm; there was a significant difference between the two groups (P < 0.001). The accuracy of the CNN classifications for the test set (89.2%) was significantly higher than that of all the radiologists (30%).ConclusionsThe CNN may have high accuracy for classification of US images of breast masses and perform significantly better than human radiologists.Trial registrationChictr.org, ChiCTR1900021375; http://www.chictr.org.cn/showproj.aspx?proj=33139.

The experiences of interval appendectomy for inflammatory appendiceal mass.

Interval appendectomy (IA) is a common treatment of acute appendicitis (AA) with inflammatory appendiceal mass (IAM). However, the management of patients with IAM is still controversial. The aim of this study was to assess the outcomes in patients with this condition. We retrospectively evaluated 244 patients with AA for their clinical characteristics and outcomes. Forty-three patients had IAM at the first medical examination. The mean age was significantly younger and the C-reactive protein level significantly higher (12.6 vs 3.1mg/dL) in patients with IAM. Thirty-four patients received IA, and nine received emergency appendectomy (EA). In the IA group, the diameter of the abscess was larger than in the EA group (31.4 vs 16.1mm). The total length of hospitalization was longer in the IA group than the EA group (20.6 vs 7.0days), although the operative time was longer in the EA group because of adhesion (101.1 vs 192.1min). Furthermore, most IA patients received a reduced-port appendectomy (74% vs 11%). Recurrence occurred in approximately 15% of patients awaiting IA. There were no complications in either group. Although each treatment approach has its advantages and disadvantages, both IA and EA can be the first option for the treatment of AA with IAM.

Diagnostic Salivary Gland Imaging - A Review

The oral and maxillofacial diagnosticians are responsible for the detection, description, differentiation and diagnosis of salivary gland disorders. The algorithm of salivary gland imaging depends on the stage of the clinical disease. For the sake of ease of description, the salivary gland disorders can be broadly divided in to inflammatory, reactive and space-occupying masses. Diagnostic imaging of salivary gland disease may be useful in distinguishing diffuse involvement from focal suppurative involvement, differentiate and identify neoplastic processes from inflammatory disease, delineate ductal morphology, identify sialoliths, identify the effect of salivary gland pathology on adjacent structures, aid in the selection of biopsy sites, etc1. This article is aimed at reviewing the different imaging modalities and the current protocol of salivary gland imaging for different clinical situations.

Тубоовариальные абсцессы в репродуктивном периоде. Методологическое обоснование органосберегающего лечения

The issues of complex treatment of patients with tubo-ovarian abscesses (TOA) in the reproductive period were considered, the main component of which is ultrasound minimally invasive surgery – drainage of purulent inflammatory tubo-ovarian mass using transvaginal ultrasound. The technique, indications and contraindications for such treatment were presented. The immune homeostasis of patients with TOA was also studied, and it was shown that they had the expansive nature of proinflammatory changes in cytokine production, as well as activation of the Th1-type lymphocytes with a simultaneous decrease in the Th2-type lymphocytes activity. Therefore, it is appropriate to include immunostimulating agents in the complex of therapeutic measures, particularly inosine pranobex. Conclusion. Drainage of TOA under the control of transvaginal ultrasound can be considered as the choice of treatment of patients of reproductive age. Sixty days after the complex treatment, the proinflammatory nature of cytokine production in these patients changed to mild proinflammatory. Key words: tubo-ovarian abscesses, ultrasound mini-surgery, drainage, inosine pranobex

ALCOHOLIC VS. NON-ALCOHOLIC CHRONIC PANCREATITIS: SURGEONS’ PERSPECTIVE FROM A TERTIARY CENTRE IN INDIA

ABSTRACT Background:Although alcohol is the most common cause for chronic pancreatitis worldwide, idiopathic type is prevalent in India. Natural history and disease progression are different between these two groups. There is paucity of data comparing surgical outcome and quality of life in these patients. Aim:To evaluate clinical features, surgical outcome and quality of life between these two groups of patients. Method:All patients with chronic pancreatitis who underwent surgery were prospectively reviewed. Results:From 98 patients, 42 were alcoholic. Number of male and the mean age at the time of operation was significantly more in alcoholic patients. Smoking, preoperative hospital admission rate and the prevalence of local complications like inflammatory pancreatic head mass, biliary stricture and left sided portal hypertension were distinctly more common in alcoholic group. Frey procedure was required more commonly in alcoholic group. Mean postoperative hospital stay and overall postoperative complication rate were comparable between the two groups. Over a median follow up of 18 months there was significant improvement in quality of life and pain score in both the groups. Improvement of physical functioning score at follow-up was significantly more in alcoholic group but the requirement for analgesic medications were significantly more in alcoholic group. However, appetite loss was more perceived by non-alcoholic group. Conclusion:Alcoholic chronic pancreatitis presents with more local complications associated with chronic pancreatitis. Frey procedure is a safe and well accepted surgery in this group. Though they required more analgesic requirement in short term follow up, other aspects of quality of life are similar to non-alcoholic group.

Concurrent Hiatal Hernia and Megaesophagus Secondary to a Nasopharyngeal Polyp in a 6-month-old Cat

Background: Nasopharyngeal polyps are benign and inflammatory masses assumed to arise from the middle ear or the eustachian tube with extension into the pharynx. The most common clinical signs associated with nasopharyngeal polyps include respiratory stertor, dyspnea, and otic discharge Neurological signs, including head tilt, facial nerve paralysis, and ataxia, might indicate concurrent involvement of the middle or inner ear. The objective of the current study is to describe a case of a feline nasopharyngeal polyp with a concurrent hiatal hernia and megaesophagus, both spontaneously resolved after removal of the polyp.Case: A 6-month-old, intact, female, domestic shorthair cat presented for evaluation of lethargy, anorexia, and upper respiratory signs, such as stridor, stertor, and dyspnea. A thoracic radiography revealed esophageal dilation caudal to the cardiac silhouette, suggestive of megaesophagus with gaseous filtration. An esophagram confirmed a hiatal hernia and megaesophagus. Computed tomography revealed a nasopharyngeal mass adjacent to the soft palate and a soft-tissue density in the right tympanic bulla. A tentative diagnosis of a nasopharyngeal polyp was made. After the ventral bulla osteotomy, the nasopharyngeal mass was removed by a gentle traction avulsion technique. Six days after the surgery, hiatal hernia and megaesophagus were spontaneously resolved. Based on histopathologic exam, the mass was found to be an inflammatory nasopharyngeal polyp. Two months after surgery, the owner reported that the patient’s condition had returned to baseline with a good appetite, and the thoracic radiography was within normal limit. Six months after the surgery, the owner reported the patient was completely recovered from the upper airway obstruction signs.Discussion: For successful treatment of a nasopharyngeal polyp, traction avulsion of the polyp with or without a ventral bulla osteotomy is recommended. However, in patients with otitis media, a ventral bulla osteotomy followed by traction avulsion of the polyp is recommended in order to reduce the rate of polyp recurrence. Common clinical signs of a nasopharyngeal polyp are stertor, stridor, dyspnea, dysphagia, and open-mouth breathing, which are identified in a chronic upper airway obstruction. A hiatal hernia secondary to a nasopharyngeal polyp has not been reported so far. However, a relationship between chronic upper airway obstruction and hiatal hernias has been proposed previously. Moreover, hiatal hernia resolved spontaneously after removal of the nasopharyngeal polyp suggests that the occurrence of the hiatal hernia was secondary to the nasopharyngeal polyp. In addition to the hiatal hernia, megaesophagus was also identified in the present case. Megaesophagus secondary to a chronic upper airway obstruction from a nasopharyngeal obstruction has been reported. However, megaesophagus is also thought to occur secondary to hiatal hernias. Therefore, in the current study, it is unclear whether the megaesophagus was solely a result of the obstructive nature of the nasopharyngeal polyp or a combination of the hiatal hernia and the nasopharyngeal polyp. In conclusion, any cat with clinical signs of an upper airway obstruction and a concurrent hiatal hernia and megaesophagus should be thoroughly investigated for a nasopharyngeal polyp, as well as other gastrointestinal and systemic causes. Furthermore, this case suggests that the prognosis for a concurrent hiatal hernia and megaesophagus is good in cats if the nasopharyngeal polyp is properly removed.Keywords: cat, hiatal hernia, megaesophagus, nasopharyngeal polyp

Obstructive Jaundice due to Pancreatic Sarcoidosis

Purpose: Gastrointestinal involvement occurs in 0.1-0.9% of patients with sarcoidosis, being the liver and stomach the most affected organs. Pancreatic sarcoidosis is rare and usually asymptomatic. We herein report a case of a patient with a suspected pancreatic head neoplasia in whom, after performing a pancreaticoduodenectomy, presented a pancreatic sarcoidosis. Method: 61-year-old female with personal history of diabetes and sarcoidosis with lung, skin, and articular involvement. Patient started with obstructive jaundice with no other symptoms. A malignant stenosis of the common bile duct was observed by echoendoscopy and a covered metal stent was inserted using an endoscopic retrograde cholangiographic technique. Histological study after fine needle aspiration were suspected of neoplasia. A CT scan showed no evidence of invasion of surrounding organs, vessels, or lymph nodes. Surgical treatment was proposed due to a suspected pancreatic head neoplasia. Result: A tumor located in the pancreatic head was observed during surgical intervention. No signs of extrapancreatic extension were appreciated. A pancreaticoduodenectomy with inter-aorto-caval and hepatic hilum lymph-node dissection was performed. Subsequent reconstruction con pancreatojejunostomy, hepaticojejunostomy and gastrojejunostomy was made. After surgery, patient presented gastroparesis that required insertion of a nasogastric tube. Histology exam revealed the presence of a non-necrotizing granulomatous inflammatory reaction in the specimen with no tumor. With this findings diagnosis of pancreatic sarcoidosis was made. Conclusion: Pancreatic sarcoidosis may present as a tumor-like mass with obstructive jaundice, weight loss, and abdominal pain as main symptoms. Differential diagnosis of an inflammatory mass from a tumor mass is difficult in theses cases.

Actinomycosis with Meckel's Diverticulitis in Adult: Case Report of a Rare Histopathology in a Rare Presentation

Introduction: Meckel's diverticulum, a true congenital diverticulum, is found in 2% of the population, is located about 2 feet from the ileocecal valve, and often is no more than 2 inches in length. Fifty percent of these cases contain ectopic tissue most commonly gastric and pancreatic. Two percent of patients are symptomatic, most often presented by the age of 2 years. Actinomycosis is a localized inflammatory mass, usually of the jaw area. The most common site of involvement in the oral cavity and cervicofacial area 50%-60% followed by thoracic 15%-25% and abdominal involvement 20%. Abdominal infection most frequently involves cecal area (usually following appendectomy), Appendix and left colon flexure. Case Presentation: A 60 years old male patient came to the hospital with lower abdominal pain, fever, constipation, nausea, and vomiting for duration of 3 days. On clinical Examination a generalized tenderness with the maximum area on right iliac fossa with guarding and rebound. Laboratory workup showed WBCS: (18,000) with neutrophilia, CRP: (340), renal and liver function test were normal. CT abdomen showed pneumoperitoneum with suspected omental abscess and pelvic collection, underlying malignant process cannot be excluded. Exploratory laparotomy finding was Meckel diverticulitis with a perforation at the tip and surrounded phlegmons of momentum and segment of the terminal ileum. The result of histopathology revealed, Meckel diverticulitis with intestinal mucosal tissue containing actinomycosis with no evidence of malignancy. Conclusion: Although Meckel's diverticulitis is a rare entity especially in adult populations, it can appear as an acute abdomen. An early diagnosis and treatment to prevent subsequent complications are essential to ensure an optimal recovery. Clinical picture, complications, and surgical incision are the same in appendicitis and Meckel's diverticulitis patients.