Intra-abdominal Locations Research Articles

Canine Intrapelvic Hemangiosarcoma in 12 Dogs (2000–2019): a Retrospective Case Series

ABSTRACT Intrapelvic hemangiosarcoma (IP HSA) is an uncommon primary location of canine HSA, and its presentation appears to be different than that of other intra-abdominal HSA locations. The objectives of this study were to report on the clinical presentation, diagnostic options, and clinical outcomes of dogs with IP HSA. Medical records from two veterinary teaching hospitals between 2000 and 2019 were reviewed for dogs diagnosed with IP HSA. Inclusion criteria consisted of a cytologic or histopathologic diagnosis of HSA from a mass arising from the muscles of the pelvic canal. Exclusion criteria included masses arising from organs within the pelvic canal, including the urethra, prostate, and urinary bladder. Twelve dogs were ultimately included in the study. Clinical presentation of IP HSA was varied, with clinical signs including hindlimb lameness, urethral obstruction, and evidence of hemoperitoneum. The median progression free survival was 92 days (range: 1–1057 days). The overall survival time was 165 days (range: 1–1170 days). IP HSA is an underreported location of canine HSA with similar biologic behavior and outcome compared with visceral HSA. It serves as an important differential in patients presenting with new-onset lameness and urethral obstruction.

2423 A Case of Budd-Chiari in the Setting of Paroxysmal Nocturnal Hemoglobinuria

INTRODUCTION: Paroxysmal nocturnal hemoglobinuria has an incidence of 1.3 case per 1 million, but the incidence is significantly increased in patients with aplastic anemia. We present a patient with a history of aplastic anemia who presents with findings concerning for Budd-Chiari. CASE DESCRIPTION/METHODS: A 44 year old man with a history of aplastic anemia presented with dyspnea and abdominal distention that started over the course of several days. At time of presentation, he appeared uncomfortable, but was hemodynamically stable. Due to initial concern for PE, CT chest was obtained and negative for pulmonary process. CT did note liver changes concerning for cirrhosis, however patient denied history of liver disease or risk factors associated with cirrhosis. Work up for causes of cirrhosis was initiated, and lab studies were unrevealing. SAAG score of 2.1 indicating portal hypertension as a cause of ascites. Due patient's fairly rapid onset of symptoms and otherwise unremarkable work up, CT liver protocol was performed with concern for Budd-Chiari. Imaging was suggestive of cirrhosis, and could not rule out Budd-Chiari, however no evidence of thrombosis was identified. Portal venous duplex suggested patent portal system without thrombosis. Given high level of suspicion for Budd-Chiari, hepatic venography was obtained, and significant for partial or complete thrombosis of all hepatic veins. In the setting of a patient with aplastic anemia and Budd-Chiari, work up for PNH was initiated and consistent with PNH. With diagnosis of cirrhosis due to Budd-Chiari, patient was referred to transplant clinic. With new diagnosis of PNH, he was started on Eculizumab with Hematology follow up. DISCUSSION: If there is concern for Budd-Chiari, diagnosis is generally with doppler ultrasonography. If US unremarkable, CT or MRI can be performed. If noninvasive diagnostic tools are nondiagnostic, hepatic venography can be performed given there is strong clinical suspicion. In PNH, thrombosis is the leading cause of death, though rare as a presenting symptom. Thromboses typically occur in unusual locations, and approximately two-thirds of thrombosis occur in intra-abdominal locations. The incidence of PNH is significantly increased in patients with aplastic anemia. In a patient with high concern for Budd-Chiari and unremarkable noninvasive testing, hepatic venography is a helpful diagnostic tool. In a patient with significant thrombosis such as this with a history of aplastic anemia, it is important to consider PNH.

Ambiguous presentation of an intra-abdominal testicular seminoma in a 40-year-old man: a case report

BackgroundCryptorchidism is the most common congenital malformation of the male genitourinary tract. The cryptorchid testis is most often located in the inguinal canal; however, intra-abdominal locations are not rare. The risk of malignancy in an undescended testis is 10% with the highest risk in an intra-abdominal testis.Case presentationHere we describe a case of a 40-year-old fertile man of Fulbe origin who presented with a non-tender lower abdominal mass of 2 months’ duration. A scrotal examination revealed just one testis in the right scrotum, with the contralateral scrotum and inguinal canal being empty. An exploratory laparotomy followed by tumor excision and histopathology revealed a testicular seminoma.ConclusionThis case report highlights the need for routine scrotal examination in all men presenting with an abdominal mass so as to rule out the possibility of an intra-abdominal seminoma.

Hemostatic Agents and Tissue Sealants: Potential Mimics of Abdominal Abnormalities

Topical tissue sealants and hemostatic agents, seen on postoperative imaging in a variety of intraabdominal and pelvic locations, have the potential to be mistaken for abdominal abnormalities, especially if the radiologist is not aware of the patient's surgical history. The normal appearance of these agents may mimic abscesses, tumors, enlarged lymph nodes, or retained foreign bodies. Therefore, it is important to be familiar with their typical imaging appearances and to review the surgical records when needed to avoid misdiagnoses. The purpose of this article is to increase the radiologist's familiarity with various types of topical tissue sealants and hemostatic agents used during surgical and percutaneous procedures in the abdomen and pelvis along with their radiologic appearances. Various types of hemostatic agents are now commonly used during surgery and percutaneous procedures in the abdomen and pelvis, and it is important to recognize the various appearances of these agents. Although there are suggestive features outlined in this article, the most important factor for the radiologist is to be aware of the patient's history and the possibility that a hemostatic agent may be present. On postoperative imaging, hemostatic agents may mimic abscesses, tumors, enlarged lymph nodes, or retained foreign bodies, and accurate diagnosis can save a patient unnecessary treatment. It is therefore crucial to incorporate knowledge of the patient's surgical history with recognition of the typical imaging appearances of hemostatic agents and other pseudolesions to avoid misdiagnoses.

An Unusual Cause of Intestinal Obstruction in a Young Female

Question: A 30-year-old woman presented with abdominal pain and distension for 1 month. There were several episodes of vomiting over the last 2 weeks. There was history of open cholecystectomy for gallstone disease 3 years back. There was no other significant past medical or family history. On examination, there was no pallor or icterus. Abdominal examination revealed abdominal distension with mild tenderness in the epigastrium. The rest of the systemic examination was unremarkable. Routine biochemical and hematologic investigations were unremarkable. A diagnosis of subacute intestinal obstruction was considered. Abdominal radiograph in erect position showed dilatation of small bowel with multiple air–fluid levels (Figure A, arrows). Ultrasonography confirmed the dilatation of small bowel loops. There was no ascites. Noncontrast axial CT of the abdomen revealed dilatation of small bowel with air–fluid levels (Figure B, short arrow) and a hyperdense intraluminal lesion showed mottled air (Figure B, arrow). Contrast-enhanced coronal reformatted image localised the intraluminal abnormality within the ileum (Figure C, arrow). The involved segment of bowel showed mild mural thickening and adjacent mesenteric fat stranding. The proximal small bowel was dilated (Figure C, short arrow). What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Gossypiboma denotes a mass of cotton sponge that is accidentally retained in the body after an operation. There are 2 usual pathological responses to retained sponge: exudative inflammatory reaction leading to abscess and aseptic/fibrotic reaction leading to a mass.1Dhillon J.S. Park A. Transmural migration of a retained laparotomy sponge.Am Surg. 2002; 68: 603-605PubMed Google Scholar Transmural migration is extremely rare. Such a migration has been reported into the intestinal lumen, urinary bladder, or thorax.1Dhillon J.S. Park A. Transmural migration of a retained laparotomy sponge.Am Surg. 2002; 68: 603-605PubMed Google Scholar Intestinal transmural migration occurs in various intraabdominal locations. It results from inflammation in the intestinal wall progressing to necrosis. After complete migration of sponge, the intestinal loop closes spontaneously. Intestinal peristaltic activity may advance the mop distally with obstruction occurring at various levels, most commonly the terminal ileum. Cases of transmural migration of surgical sponge several months to years after cholecystectomy have been reported.2Patil K.K. Patil S.K. Gorad K.P. et al.Intraluminal migration of surgical sponge: gossypiboma.Saudi J Gastroenterol. 2010; 16: 221-222Crossref PubMed Scopus (21) Google Scholar In a systematic review of transmural migration of gossypiboma, 64 cases were reported. Intestine was the most common site of impaction (75%) followed by bladder (n = 7) and stomach (n = 2). Spontaneous expulsion was reported in 4 cases only.3Zantvoord Y. Weiden R.M. van Hooff M.H. Transmural migration of retained surgical sponges: a systemic review.Obstet Gynecol Surv. 2008; 63: 465-471Crossref PubMed Scopus (47) Google Scholar Diagnosis of gossypiboma should always be considered in a patients presenting with vague abdominal complaints after surgery. Imaging, particularly computed tomography (CT), plays an important role in diagnosis. Besides confirming a diagnosis of intestinal obstruction, CT allows a rather confident diagnosis of intraluminal sponge. The CT findings of a sponge include a rounded mass with whorl-like appearance with trapped air bubbles.2Patil K.K. Patil S.K. Gorad K.P. et al.Intraluminal migration of surgical sponge: gossypiboma.Saudi J Gastroenterol. 2010; 16: 221-222Crossref PubMed Scopus (21) Google Scholar A hyperdense capsule and spotted calcification may also be seen. On ultrasonography, the sponge appears as an echogenic mass with dense shadowing. The patient underwent laparotomy and removal of surgical sponge (Figure D, arrow) from the ileum (Figure D, short arrow).

Long-term Abdominal Discomfort Related to a Paraduodenal Cystic Lesion

Long-term Abdominal Discomfort Related to a Paraduodenal Cystic Lesion

The role of endoscopic ultrasound-guided fine needle aspiration (eus-fna) for the diagnosis of intra-abdominal lymphadenopathy of unknown origin

The diagnosis of intra-abdominal lymphadenopathy of is difficult, especially when no primary lesion has been identified. We aimed to evaluate the diagnostic yield of EUS-FNA cytology in patients with enlarged intra-abdominal lymph nodes of unknown etiology. 147 patients with abdominal lymphadenopathy on imaging in whom EUS-FNA was performed with a 22-gauge needle. Performance characteristics of EUS-FNA including the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were compared between the 2 groups. AThe location of the enlarged lymph nodes was the celiac axis (8.2%), peri-gastric (34%), peri-pancreatic (25.2%), peri-portal (27.9%), and other intra-abdominal locations (4.8%). The median number of EUS-FNA passes was 5. The final diagnosis were lymphoma in (n=27), metastatic adenocarcinoma (n=44) patients, other miscellaneous malignancies (n=22) and benign disease (n=54). The sensitivity, specificity, and accuracy of EUS-FNA were 89.7, 98.3, and 93.5% respectively. A false positive FNA result was present in only 1 case (0.7%); false negative FNA results were present in eight cases (5.8%). Lymph node morphologic features of roundness, echogenicity, and homogeneity on EUS were not a predictor of lymph node malignancy. In a retrospective cohort trial, EUS-FNA was found to be highly accurate and safe in diagnosing patients with intra-abdominal lymphadenopathy of unknown etiology.

Directed submucosal tunneling permits in-line endoscope positioning for transgastric natural orifice translumenal endoscopic surgery (NOTES)

Submucosal dissection is demonstrated to be a technically feasible, safe means of obtaining peroral transgastric peritoneal access for natural orifice translumenal endoscopic surgery (NOTES). The authors hypothesized that their previously described self-approximating translumenal access technique (STAT) could be used to create directed gastric submucosal tunnels permitting in-line endoscope positioning with predetermined abdominal locations that might otherwise be difficult to access. In this study, 14 domestic farm swine underwent peroral transgastric peritoneoscopy. Under direct endoscopic visualization, a submucosal tunnel was created by dissecting between the mucosal and muscular layers of the stomach. Each tunnel was created with one of four intraabdominal locations (right upper quadrant, left upper quadrant, lesser sac, and pelvis) as the final target for in-line endoscope positioning. Once peritoneal access had been achieved, in-line positioning was assessed and peritoneoscopy was performed. The submucosal tunnels were closed with endoscopically placed clips. The animals were killed 2 weeks after the procedure, and necropsy was performed. Submucosal tunnels were successfully directed at predetermined intraabdominal targets in 12 of the 14 animals. The mean dissection time required to create the tunnel was 51 +/- 32 min. All the transgastric tunnels were successfully closed with endoscopically placed clips (mean, 3.2 +/- 1.1), and at necropsy showed no evidence of gastrotomy leak in any of the animals. One animal experienced a duodenal perforation unrelated to the transgastric tunneling and was killed on postoperative day 2. The remaining animals recovered and gained weight (mean, 5.5 +/- 1.2 kg) in the 2-week survival period. Directed submucosal dissection is technically feasible in a porcine model and permits in-line endoscope positioning with predetermined abdominal target locations. The STAT approach provides safe peritoneal access, allows for a simple reliable endoclip closure, and has an excellent short-term survival rate. This method of achieving transgastric access may be an enabling technique for future NOTES procedures.

Desmoid-type fibromatosis: from morphology to molecular genetics

Desmoid fibromatosis is a locally aggressive myofibroblastic neoplasm that may occur at abdominal, intra-abdominal and extra-abdominal locations. Most cases occur sporadically; however, a minority of cases is associated with familial adenomatous polyposis (Gardner syndrome). Morphologically, desmoid fibromatosis is an infiltrative, bland spindle cell proliferation set in a collagenized stroma. The characteristic immunophenotype is represented by expression of smooth muscle actin and β-catenin. Genetically, two distinct molecular events involve two different proteins, both members of the WNT signalling pathway. In fact, familial desmoids display germline inactivating mutations in the adenomatous polyposis coli ( APC) gene, whereas most sporadic desmoids harbour activating mutations in exon 3 of the CTNNB1 gene that encodes β-catenin. As desmoid fibromatosis represents a major therapeutic challenge, further clarification of the molecular oncogenesis of this disease may offer a rationale to develop innovative therapeutic approaches.

An Unusual Bile Collection After Postcholecystectomy Bile Leakage

Leakage from the cystic duct stumps accounts for the majority of postlaparoscopic cholecystectomy leaks. It commonly presents with a localized bile collection in the gallbladder fossa and endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is a common method of treatment. However, bile may collect in other intra-abdominal locations away from the gallbladder fossa. We present here a case of a patient who developed upper abdominal pain with distension, anorexia, and vomiting a week after laparoscopic cholecystectomy. Ultrasonography and computed tomography scans showed an intra-abdominal collection and ERCP showed a cystic duct stump leak. A biliary stent was inserted and the collection was percutaneously drained. His symptoms, however, recurred 2 weeks later, with fever, anorexia, and weight loss. Abdominal computed tomography scan showed 9.3x8.5 cm cystic mass in the left hypochondriac area and ERCP showed persistent leakage from the cystic duct stump. The stent was changed to a larger size Fr12 and the collection was again drained percutaneously. His clinical condition improved dramatically. The biliary stent was removed after 8 weeks and remained well at 9-month follow-up.

Diagnostic problems of abdominal desmoid tumors in various locations

Background Abdominal desmoid tumor is one of the forms of deep (musculoaponeurotic) fibromatosis. It occurs more often as a desmoid tumor in the abdominal wall, less often in various intra-abdominal locations. In this work, we performed retrospective study concerning diagnostic problems of this disease with the use of imaging techniques. Method Four patients (three females and one male) were examined by postcontrast CT (computed tomography) and one of them also by MR (magnetic resonance). All findings were correlated with the operational findings and histologic examination. Results The findings were typical only in the case with the lesion located in the abdominal wall, three described cases of the intra-abdominal desmoid provided a broad range of differentially diagnostic possibilities (metastases, GIT tumors, lymphomas, etc.). In particular, the findings in infiltrative processes in intra-abdominal location and retroperitoneal involvement were less typical. Ultimately, the histological findings were decisive. Conclusion The possibility of the occurrence of intra-abdominal desmoid tumor must be considered particularly in younger individuals with rapidly growing tumorous process, which does not immediately arise from the surrounding organs (digestive tract, internal genitalia, etc.), and is located in the abdominal wall or in the abdominal cavity.

In Vivo Bioluminescence Imaging of Transplanted Islets and Early Detection of Graft Rejection

Bioluminescence imaging (BLI) modalities are being developed to monitor islet transplant mass and function in vivo. The aim of this study was to use the BLI system to determine how the change in functional islet mass correlated to metabolic abnormalities during the course of alloimmune rejection in a murine transplant model. Islets obtained from a transgenic mouse strain (FVB/NJ-luc) that constitutively expressed firefly luciferase were transplanted to various implantation sites of syngeneic wild-type FVB/NJ or allogeneic Balb/C streptozotocin-induced diabetic recipients. In vivo graft luminescent signals were repeatedly measured after transplantation using the BLI system and related to blood glucose levels and graft site histologic findings. The BLI signals were detected in as few as 10 islets implanted in the renal subcapsular space, intrahepatic, intraabdominal, and subcutaneous locations. There was a linear relationship between the number of islets transplanted and luminescence intensity. In isografts, stable luminescence intensity signals occurred within 2 weeks of transplantation and remained consistent on a long-term basis (18 months) after transplantation. In allografts, after normoglycemia was achieved and stable luminescence intensity occurred, graft bioluminescent intensity progressively decreased several days before permanent recurrence of hyperglycemia as a result of histologically proven rejection ensued. Bioluminescence imaging is a sensitive method for tracking the fate of islets after transplantation and is a useful method to detect early loss of functional islet mass caused by host immune responses even before overt metabolic dysfunction is evident. Bioluminescence imaging holds promise for use in designing and testing interventions to prolong islet graft survival.

Glomus tumor of the mesocolon

Glomus tumors are rare distinctive benign neoplasms, which arise from modified smooth muscle cells of the normal glomus body and are most commonly located in the subungual region of the finger. Intraabdominal locations are relatively rare. We report a case of glomus tumor of the mesocolon in a 10-year-old girl. Surgical exploration showed a lesion in the transverse mesocolon, which was excised. Histopathology showed it to be a glomus tumor of the mesocolon.

Anaplastic lymphoma kinase (ALK) expression in the inflammatory myofibroblastic tumor: a comparative immunohistochemical study.

Inflammatory myofibroblastic tumor (IMT) is an uncommon mesenchymal neoplasm with a variable histologic appearance that may mimic other spindle cell processes, particularly nodular fasciitis, desmoid tumor, and in intra-abdominal locations, gastrointestinal stromal tumor. Recently, gene fusions involving ALK at chromosome 2p23 have been described in IMTs. The resultant ALK protein overexpression in the myofibroblastic component of these tumors is detectable by immunohistochemistry. We examined 73 IMTs, 20 cases of nodular fasciitis, 15 desmoid fibromatoses, and 15 gastrointestinal stromal tumors by immunohistochemistry using ALK-11, a rabbit polyclonal antibody that recognizes the C-terminus of the protein. ALK positivity was detected in 44 of 73 (60%) IMTs. All cases of nodular fasciitis, desmoid fibromatosis, and gastrointestinal stromal tumors were ALK negative (p < 0.001). These findings demonstrate that ALK positivity is common in IMTs, and immunohistochemistry using anti-ALK antibodies can be helpful in the differential diagnosis of these neoplasms. In addition, anti-ALK staining seems to correlate with those IMTs that have the typical tri-patterned histologic appearance and clinical presentation, providing additional support to the premise that IMT is a distinctive clinicopathologic entity within the broad category of inflammatory pseudotumors.

Vitamin E levels in superficial and intra-abdominal locations of white adipose tissue in the rat

Concentrations of RRR-α-tocopherol (vitamin E) were measured in white adipose tissue (WAT) from three superficial and three intra-abdominal locations of rats fed diets using low-, normal-, or high-vitamin E content for 3 months. Vitamin E levels in WAT were responsive ( P < 0.05) to the amount of the vitamin in the diet. Irrespective of treatment, superficial locations of adipose tissue accumulated four to six times more vitamin E than the intra-abdominal locations. Some of the rats in the low and high vitamin E diet were switched to the opposite diet and the repletion and depletion of the vitamin were monitored for 10, 20, and 30 days after the diet change. Thirty days after the change in diet, WAT from superficial and intra-abdominal locations did not respond during depletion. The deposition of vitamin E in all superficial locations was more rapid than in the intra-abdominal locations after the diet change from low vitamin E to high vitamin E.

Three Dimensional Sound and Vibration Frequency Responses of the Sheep Abdomen

There is growing awareness and concern about reproductive hazards in the workplace. Sound and vibration have long been recognized as occupational hazards, but there are no guidelines or consensus standards for foetal protection. A three-dimensional analysis of sound pressure level (SPL) within the abdomen was used to show how sound and vibration of various frequencies are transmitted throughout the abdominal segment of sheep. Sinusoidal stimulation was provided with a mechanical vibrator placed on the anterior abdominal wall just posterior to the umbilicus. A hydrophone was placed at 45 intraabdominal locations within a space measuring 20×20×25 cm centered over the mechanical oscillator. Pure tones of 10, 100, 1000 and 2000 hertz were used to stimulate the abdominal wall. Intraabdominal SPL was negatively correlated with distance between the hydrophone and the vibrator (p&lt;0.0001) and was negatively correlated with frequency of vibration (p&lt;0.0001). The rate at which the system attenuated high frequencies was greater than for lower frequencies and it attenuated higher frequencies more uniformly throughout the entire abdomen (p&lt;0.0001).