Intraperitoneal Mass Research Articles

Obturator nerve schwannoma: a case report and review of the robotic literature

Abstract Obturator schwannomas are rare and often misdiagnosed as intraperitoneal pelvic masses. The optimal surgical approach for their resection is unclear. This study presents a case demonstrating the safe use of robotics for resecting a benign pelvic schwannoma and reviews the literature on robotic cases. Here, a 40-year-old woman with right lower quadrant pain underwent imaging, revealing a 4.6 × 3.3 × 3.6 cm pelvic mass. She had a robotic-assisted laparoscopic excision, with pathology confirming a benign schwannoma. Complete tumor resection is the gold standard. The use of minimally invasive robotic-assisted surgery is increasing due to improved visualization, efficient movement, and safety, making it a viable option for resecting obturator schwannomas.

Giant intra-abdominal desmoid-type fibromatosis infiltrating into the pancreas

Abstract: Intra-abdominal desmoid-type fibromatosis is a proliferative fibroblastic lesion that constitutes 8% of all desmoid tumors and 0.03% of all neoplasm. It is histologically benign with a local aggressive nature and recurs even after excision. It can occur sporadically and or associated with familial adenomatous polyposis mutation. The present case is a 25-year-old female admitted with a chief complaint of abdominal mass gradually increasing in size in the last 6 months. Ultrasound of the whole abdomen initially suggested it to be a uterine/ovarian mass, which is further detailed by the contrast-enhanced computerized tomography (CT) scan. The CT scan showed a large heterodense intraperitoneal mass lesion measuring 34 cm × 25 cm × 16 cm with foci of calcification and necrosis. The mass extended superomedially. It displaced and compressed the stomach wall. It was abutting the peritoneum and was associated with diffuse peritoneal thickening anterolaterally. Posteriorly it was abutting small bowel loops and inferiorly extending into the pelvis and compressing the urinary bladder wall. Posterosuperiorly seems to abut the left kidney and spleen. Desmoid tumor and gastrointestinal stromal tumor (GIST) remained as differentials radiologically and then the patient underwent laparotomy. Histology and immunohistochemistry confirmed it to be fibromatosis. It is, therefore, justified to describe the tumor by considering its rarity, difficulties in diagnosis, and therapeutic ambit.

Determining the residual volume in peritoneal dialysis using low molecular weight markers.

Variation in residual volume between peritoneal dialysis dwells creates uncertainty in ultrafiltration determination, dialysis efficiency, and poses a risk of overfill if the residual volume is large. Measuring the dilution of a marker molecule during fluid fill offers a convenient approach, however, estimation accuracy depends on the choice of dilution marker. We here evaluate the feasibility of creatinine and urea as dilution markers compared to albumin-based residual volumes and three-pore model estimations. This clinical, retrospective analysis comprises 56 residual volume estimations from 20 individuals, based on the dilution of pre-fill dialysate creatinine, urea and albumin concentrations during the dialysis fluid fill phase. Outcomes were compared individually. Bias induced by ultrafiltration, marker molecule mass-transfer and influence of fluid glucose contents was quantified using the three-pore model. Linear regression established conversion factors enabling conversion between the various marker molecules. Creatinine-based calculations overestimated residual volumes by 115 mL (IQR 89-149) in 1.5% dwells and 252 mL (IQR 179-313) in 4.25% glucose dwells. In hypertonic dwells, ultrafiltration was 52 mL (IQR 38-66), while intraperitoneal creatinine mass increased by 67% during fluid fill, being the leading cause of overestimation. Albumin-based volumes conformed strongly with three-pore model estimates. Correction factors effectively enabled marker molecule interchangeability. Mass-transfer of low molecular weight marker molecules is associated with residual volume overestimation. However, by applying correction factors, creatinine and urea dilution can still provide reasonable estimates, particularly when the purpose is to exclude the presence of a very large residual volume.

Primary retroperitoneal paraganglioma mimicking gastric GIST: Case report

Introduction: A paraganglioma is a tumor originating from the sympathetic or parasympathetic nervous system. Its diagnosis is sometimes difficult, especially if it occurs in an atypical location. We report the case of a patient who presented with a diagnosis of gastric GIST and underwent surgical resection and whose postoperative histopathological examination revealed that it was a paraganglioma. Case report: A 38-year-old female patient who underwent cesarean section one year ago, had isolated epigastralgia for two years, the clinical examination was without abnormalities, and the patient benefited from an oesogastroduodenal fibroscopy showing an extrinsic compression aspect at the level of the greater curvature, the abdominal CT scan showed an 8 cm intraperitoneal mass in contact with the lesser gastric curvature evoking a gastrointestinal stromal tumor aspect. The biological work-up was without abnormalities. Surgery was performed to remove the retroperitoneal mass and a final diagnosis of paraganglioma was made, eliminating the initial diagnosis of gastrointestinal stromal tumor. Discussion: There are lessons to be learned from our case first, paraganglioma can be misdiagnosed. Second, misdiagnosis can be misled by clinical diagnosis and imaging. Third, misdiagnosis can lead to high morbidities and mortality. Conclusion: The correct knowledge of this pathology, including the differential diagnosis, is fundamental to establishing the correct diagnosis. In addition, close follow-up of these cases should be considered because of the high risk of metastatic disease.

Various Clinical Manifestation of Omphalomesenteric Duct Remnant in a Child: A Case Report

Omphalomesenteric duct (OMD) remnant is a condition in which the omphalomesenteric duct fails to obliterate completely or partially. Failure in this step can produce various patterns, such as a vitelline cyst, umbilical sinus, polyp, Meckel’s diverticulum, and patent OMD. Various clinical manifestations of OMD rarely occur in one patient. We present the case of omphalomesenteric duct remnant, manifested as anterior wall abdominal mass, intraperitoneal hemorrhage, and obstructive ileus. Case report: A four-year-old girl was referred to our hospital with obstructive ileus and abdominal wall mass on the left lower quadrant. Contrast-enhanced abdominal computed tomography (CT) scan found an irregular cystic mass in the abdominal cavity that adheres to the anterior wall of the abdomen and bowel structure with a fluid-solid level without enhancement. Further medical history was taken and found a history of intermittent watery umbilical discharge that appears three times in 2 years after birth. Omphalomesenteric duct remnant was suspected, then proceed to exploratory laparotomy. We found intraperitoneal hemorrhage and 5x4 centimeters frail mass adhering to the anterior wall of the abdomen on the left side of the umbilicus. Histopathological examination confirmed intestinal tissue, suggesting remnants of the omphalomesenteric duct and pancreatic tissue with a chronic inflammatory pattern. Diagnosing omphalomesenteric duct remnant could be challenging and should be considered a differential diagnosis of obstructive ileus, particularly if persistent umbilical discharges are also present. On the other hand, early diagnosis and appropriate management of persistent umbilical discharge could prevent a greater outcome.

PCB169 exposure aggravated the development of non-alcoholic fatty liver in high-fat diet-induced male C57BL/6 mice.

Polychlorinated biphenyls (PCBs) are lipophilic environmental toxicants. Epidemiological studies have established a link between PCBs and both metabolic syndrome and nonalcoholic fatty liver disease (NAFLD). Multiple studies have reported that exposure to both PCB156 and PCB126 among the 12 dioxin-like PCBs leads to the development of NAFLD. However, studies to elucidate whether PCB169 induces the development of NAFLD by constructing in vivo models have not been reported. Therefore, we evaluated the effects of exposure to PCB169 (5 mg/kg-bw) on hepatic lipid metabolism in C57BL/6 mice from control diet and high-fat diet cohorts. The results showed that PCB169 exposure reduced body weight and intraperitoneal fat mass in mice on the control diet, but the liver lipid levels were significantly increased, exacerbating NAFLD in mice on a high-fat diet. Through transcriptomics studies, it was found that PCB169 exposure induced significant up-regulation of Pparγ, Fasn, and Aacs genes involved in hepatic lipogenesis, as well as remarkable up-regulation of Hmgcr, Lss, and Sqle genes involved in cholesterol synthesis. Additionally, there was notable down-regulation of Pparα and Cpt1 genes involved in lipid β-oxidation, leading to abnormal lipid accumulation in the liver. In addition, we found that PCB169 exposure significantly activated the Arachidonic acid metabolism, PPAR signaling pathway, Metabolism of xenobiotics by cytochrome P450, and Retinol metabolism pathways, and so on. Our study suggests that PCB169 can modify gene expression related to lipid metabolism, augument lipid accumulation in the liver, and further contribute to the development of NAFLD, thereby revealing the detrimental effects associated with PCB exposure on animal growth and metabolism.

Evaluation of Ouabain's Tissue Distribution in C57/Black Mice Following Intraperitoneal Injection, Using Chromatography and Mass Spectrometry.

Cardiotonic steroids (CTSs), such as digoxin, are used for heart failure treatment. However, digoxin permeates the brain-blood barrier (BBB), affecting central nervous system (CNS) functions. Finding a CTS that does not pass through the BBB would increase CTSs' applicability in the clinic and decrease the risk of side effects on the CNS. This study aimed to investigate the tissue distribution of the CTS ouabain following intraperitoneal injection and whether ouabain passes through the BBB. After intraperitoneal injection (1.25 mg/kg), ouabain concentrations were measured at 5 min, 15 min, 30 min, 1 h, 3 h, 6 h, and 24 h using HPLC-MS in brain, heart, liver, and kidney tissues and blood plasma in C57/black mice. Ouabain was undetectable in the brain tissue. Plasma: Cmax = 882.88 ± 21.82 ng/g; Tmax = 0.08 ± 0.01 h; T1/2 = 0.15 ± 0.02 h; MRT = 0.26 ± 0.01. Cardiac tissue: Cmax = 145.24 ± 44.03 ng/g (undetectable at 60 min); Tmax = 0.08 ± 0.02 h; T1/2 = 0.23 ± 0.09 h; MRT = 0.38 ± 0.14 h. Kidney tissue: Cmax = 1072.3 ± 260.8 ng/g; Tmax = 0.35 ± 0.19 h; T1/2 = 1.32 ± 0.76 h; MRT = 1.41 ± 0.71 h. Liver tissue: Cmax = 2558.0 ± 382.4 ng/g; Tmax = 0.35 ± 0.13 h; T1/2 = 1.24 ± 0.7 h; MRT = 0.98 ± 0.33 h. Unlike digoxin, ouabain does not cross the BBB and is eliminated quicker from all the analyzed tissues, giving it a potential advantage over digoxin in systemic administration. However, the inability of ouabain to pass though the BBB necessitates intracerebral administration when used to investigate its effects on the CNS.

Laparoscopic assisted removal of large ovarian mass causing precocious puberty in an infant—a case report

BackgroundSex cord and stromal tumors are a heterogeneous group of tumors that arise from gonadal sex cord cells, gonadal stromal cells, or both. They are divided into pure stromal tumors, pure sex cord tumors, and mixed tumors. Some of these tumors are hormonally active, producing androgens and estrogens, and may therefore exhibit virilization or excess estrogen. Sertoli-Leydig cell tumors are rare tumors belonging to mixed tumors representing less than 0.5% of ovarian tumors. Few cases have been reported in the medical literature.Case presentationWe report the case of a 1-year-old girl who was admitted for breast lumps and pubic hair with intermittent painless vaginal bleeding in the past 2 weeks. The abdominal examination objectified the presence of an intraperitoneal mass to which an abdominal ultrasound and computerized tomography (CT) scan had confirmed the presence of a right ovarian mass. A laparoscopy was performed which showed an encapsulated mass arriving from the right ovary replacing the normal ovarian tissue. Laparoscopic-assisted removal of the entire mass was done. The postoperative course was uneventful. The histopathological study demonstrated an intermediately differentiated Sertoli cell tumor with an intact capsule, no lymphovascular invasion, or heterologous elements (TNM stage 1).ConclusionsAlthough Sertoli-Leydig tumors are commonly seen after the second decade of life in young women, their discovery before puberty is not uncommon. Mass syndrome and signs of virilization are two frequently reported signs that should prompt the clinician to mention this entity among the differential diagnoses. The first-line radiological examination is pelvic ultrasound. The treatment is mainly based on surgery. The prognosis is excellent especially if the tumor is well differentiated.

Spontaneous Lymphoma in a SMP30 Knock-Out C57BL/6 Mouse

Abstract 70-weeks-old female C57BL6 senescence marker protein 30 knock out mice exhibited anorexia, lethargy and enlarged abdomen because of an intraperitoneal mass. On necropsy, the mouse revealed a large brown-whitish mass located on the mesentery. The mass also exhibited systemic metastasis and spread over in various organs. On microscopic findings, the neoplastic masses were mainly composed of neoplastic round cells characterized by severe anisokaryosis, narrow cytoplasm, round nuclei, prominent nucleoli, and numerous mitotic figures (13-15 in a 400X field). Consequently, the present case was diagnosed as a metastatic lymphoma arising from a mesenteric lymph node, the tumor spread to other organs such as the intestine, kidney and thoracic cavity. According to previous studies, SMP30 plays an important role in inhibiting cancer in both human and mouse. Taken together, it seems that the present case can be used as a valuable asset for evaluating the potential risks of SMP30 depletion in developing lymphoma.

A Rare Case of Ectopic Liver Presenting as an Intraperitoneal Mass: A Case Report and a Concise Case Review

Abstract Introduction/Objective Ectopic liver is a rare developmental abnormality, in which liver tissue is localized outside the normal liver and has no connection to the native liver. The presence of ectopic liver tissue has been reported most commonly in the gall bladder. Intrathoracic cavity, kidney, abdominal wall, and esophagus are the other sites where it has been identified. But its presence in the intraperitoneal has rarely been reported previously. We report such a case in a young female. Methods/Case Report A 27-year-old female presented with shortness of breath and was diagnosed to have pulmonary embolism. On imaging, she incidentally was found to have a well circumscribed 4.4 x 4.8 cm enhancing mass in the left sub- diaphragmatic region wedged between splenic hilum and greater curvature of the stomach. Based on imaging diagnosis of accessory spleen was considered. She underwent a nuclear medicine scan that was not consistent with the accessory spleen. Esophagogastroduodenoscopy identified a mass that showed abutment of the mucosa of stomach. Cytology showed rare polygonal benign cells which were non-diagnostic. A robotic laparoscopic-assisted abdominal mass excision was performed, identifying a mass abutting, but not adherent, to the spleen, pancreas and stomach. Histopathological examination revealed benign liver tissue with several portal triads. Immunohistochemical staining showed positivity for Hepar 1 and arginase; reticulin stain; together supporting it to be a benign hepatic lesion. This was finally diagnosed as benign ectopic liver Results (if a Case Study enter NA) NA. Conclusion Ectopic liver is a rare condition, with an incidence between 0.24%-0.47%. It can be associated with other congenital anomalies but most crucial implication, is the development of malignancy. It is sometimes, difficult to identify ectopic liver on imaging modalities. It is important to be aware of such rare findings for optimal patient care.

S2219 A Rare Subtype of Colorectal Cancer Presenting as a Contained Perforation

Introduction: Colonic perforation comprises 3-10% of the initial presentation of Colorectal Cancer (CRC). Signet Ring Cell Carcinoma and Mucinous Adenocarcinoma are 2 distinct subtypes which occur with a very low incidence of 10-20% and 0.9-4%, respectively. Both are usually diagnosed at an advanced stage and have an overall worse prognosis than other types of CRC. Here we present a rare case of colonic mucinous adenocarcinoma with signet ring cell features manifesting as a contained perforated intra-abdominal mass necessitating surgery. Case Description/Methods: A 60-year-old male presented with fatigue, shortness of breath and anemia with hemoglobin of 4.8 g/dL. A computed tomography (CT) scan of the abdomen and pelvis was obtained which showed an intraperitoneal mass with a central necrotic component and air, suggesting communication to the small bowel. Due to the initial concern of a possible contained perforation, colonoscopy was deferred despite the patient never having one previously. Ultimately, the patient underwent a diagnostic laparoscopy which showed a large intra-abdominal mass with a mucinous surface involving multiple parts of the small bowel and sigmoid colon. This mass was removed along with a small bowel and sigmoid colon resection. Pathology was notable for moderately differentiated mucinous adenocarcinoma of the sigmoid colon with focal signet ring features with negative margins and no evidence of lymphovascular invasion. He was eventually discharged with instructions to follow up with Oncology for further treatment. (Figure) Discussion: Mucinous adenocarcinoma is characterized by the presence of abundant extracellular mucin which accounts for at least 50% of the tumor volume. Signet ring cells have copious amounts of mucin in the cytoplasm and nuclei located at the cell periphery. These lesions are usually located in the right colon and share similar characteristics on CT imaging including segments of concentric bowel wall thickening and ulcerations. Studies have shown that even a minor signet-ring cell component in CRC was associated with higher patient mortality. This becomes evident as these tumors diffusely infiltrate the submucosa with full thickness involvement of the bowel wall and have a high propensity for pelvic, peritoneal and ovarian metastasis. Treatment centers on surgical resection with adjuvant chemotherapy showing some benefit. Our case highlights an atypical presentation of a rare subtype of CRC for which gastroenterologists should maintain a high index of suspicion.Figure 1.: (Top) Signet Ring Cells in background of mucus (from sigmoid colon) (Bottom) Computed Tomography (CT) scan showing an intra-abdominal mass with a contained perforation.

The dilemma in management of desmoid tumour: A case report

IntroductionDesmoid tumours are rare benign tumours. The tumours may develop sporadically or they may be linked to familial adenomatous polyposis (FAP) in Gardner’s syndrome.AimThis article highlights a young lady with an intra-abdominal desmoid tumour that manifested as an acute abdomen and we discuss our management strategy.Case studyA 24-year-old lady with a known FAP who had undergone a panproctocolectomy with an ileal pouch-anal anastomosis and total thyroidectomy, later was complicated with acute abdomen for symptomatic desmoid tumour. Computed tomography of the abdomen showed a large intraperitoneal heterogenous mass with small bowel displacement and was confirmed by magnetic resonance imaging. An exploratory laparotomy and en-bloc resection of the tumour with an end ileostomy were performed.Results and discussionIntra-abdominal desmoid tumours usually present as a painless slow-growing mass, however, in severe form, it can cause bowel ischemia, intestinal obstruction, or deterioration of function in the ileoanal anastomosis, among post total colectomy. Surgery is indicated upfront in specific clinical scenarios namely complications (occlusion, perforation, or bleeding) or major cosmetic issues.ConclusionsDesmoid tumour, despite being benign, is challenging to manage due to its compressing nature. As a key point, the diagnosis of a desmoid tumour should be suspected and followed up closely in patients with a previous history of FAP in combination with extracolonic manifestation.

Giant omental lipoma, a rare etiology of right-iliac fossa pain in adult: A surgical case report.

BackgroundOmental lipoma is an uncommon abdominal tumor of mature fat cells. Those benign tumors are usually asymptomatic but occasionally can cause signs and symptoms based on their location, size, and presence of complications. Radiological investigations such as Abdominal ultrasonography (USG) and computed tomography (CT) are crucial to evaluate and diagnose intra-abdominal tumors, especially omental lipomas.PresentationA 61-year-old male patient presented to our hospital with right iliac fossa pain. Physical examination and laboratory test results were normal. The performed abdominal CT scan revealed a large right-sided intraperitoneal mass measuring about 2.4 × 10 × 20 cm. Then, an ultrasound-guided biopsy was done and the picture was most consistent with lipoma. So, surgical intervention was decided and omental lipoma was completely exteriorized via a laparoscopic approach. The weight of the excised omental mass was 2.45 kg, measuring 23 × 18 × 7 cm. The resected specimens, including omental lipoma and omental lymph nodes, were sent for histopathological studies. The postoperative period was uneventful.DiscussionOmental lipoma is an unusual entity that occurs often in children and rarely in adults. The clinical features of omental lipomas include abdominal discomfort, abdominal lump, abdominal pain, nausea, and/or weight loss. Diagnosis of the omental lipoma relies on imaging and physical examination, which was normal in the presented case. Abdominal CT provides definitive fat content characterization and its localization within the omentum.ConclusionDue to the rare etiologic origin of omental lipomas, we report the case of a 61-year-old male with right iliac fossa pain, found to be caused by detected giant omental lipoma.

Histomorphological Spectrum and Immunohistochemical Features of Gastrointestinal Stromal Tumour: A Series of Eight Cases

Gastrointestinal Stromal Tumours (GISTs) are rare tumours of the Gastrointestinal Tract (GIT), consisting of <1% of all primary GIT neoplasms. Recent studies show an increased incidence, which may be due to improved diagnostic facilities. In contrast to the literature’s judgement and the findings of many Western research, which state that the stomach is the most common place, it was observed that the small intestine was more common. Consequently, the goal of this case series was to characterise the clinicopathological, histomorphological, and immunohistochemical spectrum of GISTs as well as their risk categorisation in accordance with the modified Miettinen and Lasota’s algorithm. Eight patients with GISTs diagnosed between January 2017 and December 2020 at tertiary care centre of Gujarat, India are presented in this case series. There was one young woman among the patients, others were middle or old age male or female and had a median age of 58.5 years. The most typical presentation was abdominal pain, albeit in one instance it was an unexpected discovery. One example of extra Extra GISTs (EGIST), where there were several retro and intraperitoneal masses, and one small intestinal GIST each had lymphoma as the tentative clinical diagnosis. Predominant spindle cell morphology was observed in contrast to other studies. Even if molecular studies are not available in resource-limited countries, the basic Immunohistochemistry (IHC) panel is the most useful in the final diagnosis. Risk stratification criteria are helpful for prognostication and further management with the use of appropriate targeted therapies.

Inflammatory Myofibroblastic Tumor in Adult: A Rare Case

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm of intermediate biologic potential. Inflammatory myofibroblastic tumor (IMT) of the alimentary tract often occurs in children or young adults, but may occur at any age. The lung is the most commonly affected location. However, it may appear in small bowel mesentery especially the distal ileum, mesotransverse colon, or greater omentum. A 35 years old female presented to out-patient department with complaint of mass in right abdomen since 1 month associated with loss of weight. Computed tomography of abdomen revealed a solid intraperitoneal mass arising from bowel mesentery. Laparoscopic excision of the tumor was performed and the histopathological examination of the mass revealed it to be an inflammatory myofibroblastic tumor arising from the omentum and large bowel mesentery. The post- operative period was uneventful with no evidence of tumor recurrence at follow up at 2 years. Inflammatory myofibroblastic tumor is a rare soft tissue tumor usually arising from lungs but tumor arising from the omental-mesenteric origin has also been documented. The precise diagnosis is made only by the histopathological evidence. Surgical resection is the treatment of choice.

S3168 Metastatic Breast Cancer to a J-Shaped Muscular Bag – The Stomach

Introduction: Female breast cancer was the leading cause of global cancer incidence in 2020, with an estimated 2.3 million new cases, representing 11.7% of all cancer cases. The most common primary target sites of breast cancer metastasis are bone, lung, liver, and brain. The stomach is an infrequent site of breast cancer metastasis, accounting for an incidence ranging from 0.3% in retrospective studies to 8-18% in autopsy series. Needless to say, metastasis to the stomach from any primary tumor is itself atypical, with an incidence of 0.2-1.7%. We present a case of breast cancer metastasis to the stomach from a rare histological subtype of breast cancer- glycogen-rich, clear cell breast carcinoma. Case Description/Methods: 75- year-old female with clear cell glycogen rich invasive carcinoma, stage IIIB of the right breast presented to the emergency department (ED) complaining of fatigue and weakness for two days. Vital signs were normal. Physical examination revealed ataxic gait and right-sided hemiparesis. Labs showed a hemoglobin of 7.5 g/dl (baseline 9.8 g/dl) and hematocrit 23.5% (baseline 30%). The following day her hemoglobin asymptomatically dropped to 6.8 g/dl, and a repeat reading showed a further decline to 5.8 g/dl. Two units of packed red blood cells (PRBC) were transfused, which increased her hemoglobin to 7.8 g/dl. Fecal Occult Blood Test (FOBT) was positive, and gastroenterology was consulted to investigate further. Computerized Tomography (CT) of the abdomen showed a 4.4 cm intraperitoneal mass in the left mid-abdomen highly suggestive of metastasis. Esophagogastroduodenoscopy (EGD) revealed several gastric ulcers on the greater aspect of the stomach's body located on the mucosal mound or raised mucosa (Figure 1). Given the undermining margins and the ulcer's location, there was increased suspicion for malignancy and she was diagnosed with metastatic poorly differentiated gastric adenocarcinoma. Due to the patient's low-performance status, hospice/palliative care was pursued. Discussion: The exact mechanism of gastric metastasis of breast cancer is still unclear. Gastric metastasis can have a negative impact on survival and must be investigated in patients with breast cancer who present with non-specific gastrointestinal symptoms. There should be a very high index of suspicion for a prompt diagnosis. In patients with a history of breast cancer, gastric endoscopy should be offered in cases of GI symptoms, even when the symptoms are vague.Figure 1.: Gastric perforation secondary to malignant gastric outlet obstruction.

An unusual cause of a toddler with a big belly, abdominal lymphatic malformation case report

: Abdominal pain is one of the most common complaints seen in the pediatric emergency department (PED). Because of the broad range of potential diagnoses, it can pose challenges in the diagnostic evaluation and treatment in the young child. A 3-year-old previously healthy girl presented to our PED with abdominal pain, abdominal distention, poor appetite, and recent weight gain. Physical examination was notable for a significantly distended taut abdomen in an otherwise well appearing child with normal vital signs. Initial evaluation yielded anemia, elevated inflammatory markers, and an abdominal ultrasound (US) showing a large amount of complex intra-abdominal ascites without definite intra-peritoneal mass. Pediatric surgery, pediatric gastroenterology, and pediatric oncology were consulted. A magnetic resonance imaging (MRI) of the abdomen was performed and revealed a large amount of intraperitoneal fluid with a component of internal complexity and no suspicious enhancement to suggest overt malignant process. She was ultimately diagnosed with a large congenital omental cyst that required resection and omentectomy. Pathology was consistent with a macrocystic lymphatic malformation. Lymphatic malformations are uncommon pediatric lesions, accounting for only 5% of benign tumors in childhood. Common locations include the neck, axillae, and rarely involve the gastrointestinal tract. Clinical presentation varies depending on the size and location of the tumor. Many present later in life due to their diagnostic challenges.

An unusual origin of liposarcoma in an elderly man: a case report

Liposarcoma is a type of cancer with mesenchymal origin in which the bulk of tumor differentiates into adipose tissue. Liposarcoma can be found in any part of the body with fat cells, but most cases occur in the muscles of the limbs or in the retroperitoneum. Here we report a case of an elderly man with an uncommon origin of liposarcoma. A 76-year-old man presented to hospital with gastrointestinal symptoms and a palpable mass over lower abdomen. Abdominal computer tomography revealed colonic tumor with another huge intraperitoneal mass, looks like originated from mesentery of small intestine. The patient underwent an exploratory laparotomy. During operation, despite colon cancer, a 17cm mass, originated from distal ileum mesentery was noted. The specimen histopathology of the tumor resection showed well-differentiated liposarcoma with prominent myxoid stroma. Finally, the patient was discharged on the tenth postoperative day. Most of liposarcomas origin from the extremities, retroperitoneum and inguinal region. However, we have chance to find liposarcomas everywhere in our body. In our case, it was a liposarcoma derived from mesentery of small intestine and it had few reports before.

A giant peritoneal loose body impacted in the pelvic cavity, a rare and interesting finding during laparotomy

Background: Peritoneal loose bodies (sometimes termed as peritoneal mice) are rare findings that may be discovered incidentally during laparotomy or at autopsy. They consist of densely hyalinized, laminated, fibrous tissue which is arranged in multiple concentric layers. They arise from epiploic appendices which undergo torsion, ischemia and necrosis, saponification and then calcification. In most patients they cause no symptoms or nonspecific symptoms. Case Presentation: A 67-year-old male presented with lower abdominal pain and constipation for 3 months. Abdominal examination showed a fixed palpable mass in the lower abdomen arising from the pelvic cavity, the mass was firm, not tender and not mobile. Magnetic resonance imaging of the pelvis showed a large lobulated 10×70 cm abdominal mass with no significant enhancement. During laparotomy there was a large smooth and firm intraperitoneal mass which was attached by small pedicle to the omentum. Extraction of the mass was performed. The cut surface of the mass showed multiple concentric layers with a central stone like structure. Histopathologic evaluation revealed extensive fibrous tissue with mild inflammatory cells infiltration and areas of calcifications. Conclusion: The most important critical step in the management of peritoneal loose bodies is to distinguish them from other intraperitoneal masses particularly tumors which is sometimes very difficult and may require some invasive procedures including surgery, surgery may also be required for large symptomatic masses.

Branched-chain amino acid metabolism, insulin sensitivity and liver fat response to exercise training in sedentary dysglycaemic and normoglycaemic men

Aims/hypothesisObesity and insulin resistance may be associated with elevated plasma concentration of branched-chain amino acids (BCAAs) and impaired BCAA metabolism. However, it is unknown whether the insulin-sensitising effect of long-term exercise can be explained by concomitant change in BCAAs and their metabolism.MethodsWe included 26 sedentary overweight and normal-weight middle-aged men from the MyoGlu clinical trial, with or without dysglycaemia, for 12 weeks of supervised intensive exercise intervention, including two endurance and two resistance sessions weekly. Insulin sensitivity was measured as the glucose infusion rate (GIR) from a hyperinsulinaemic−euglycaemic clamp. In addition, maximum oxygen uptake, upper and lower body strength and adipose tissue depots (using MRI and spectroscopy) were measured, and subcutaneous white adipose tissue (ScWAT) and skeletal muscle (SkM) biopsies were harvested both before and after the 12 week intervention. In the present study we have measured plasma BCAAs and related metabolites using CG-MS/MS and HPLC-MS/MS, and performed global mRNA-sequencing pathway analysis on ScWAT and SkM.ResultsIn MyoGlu, men with dysglycaemia displayed lower GIR, more fat mass and higher liver fat content than normoglycaemic men at baseline, and 12 weeks of exercise increased GIR, improved body composition and reduced liver fat content similarly for both groups. In our current study we observed higher plasma concentrations of BCAAs (14.4%, p = 0.01) and related metabolites, such as 3-hydroxyisobutyrate (19.4%, p = 0.034) in dysglycaemic vs normoglycaemic men at baseline. Baseline plasma BCAA levels correlated negatively to the change in GIR (ρ = −0.41, p = 0.037) and dot{V}{mathrm{O}}_{2max } (ρ = −0.47, p = 0.015) after 12 weeks of exercise and positively to amounts of intraperitoneal fat (ρ = 0.40, p = 0.044) and liver fat (ρ = 0.58, p = 0.01). However, circulating BCAAs and related metabolites did not respond to 12 weeks of exercise, with the exception of isoleucine, which increased in normoglycaemic men (10 μmol/l, p = 0.01). Pathway analyses of mRNA-sequencing data implied reduced BCAA catabolism in both SkM and ScWAT in men with dysglycaemia compared with men with normoglycaemia at baseline. Gene expression levels related to BCAA metabolism correlated positively with GIR and markers of mitochondrial content in both SkM and ScWAT, and negatively with fat mass generally, and particularly with intraperitoneal fat mass. mRNA-sequencing pathway analysis also implied increased BCAA metabolism after 12 weeks of exercise in both groups and in both tissues, including enhanced expression of the gene encoding branched-chain α-ketoacid dehydrogenase (BCKDH) and reduced expression of the BCKDH phosphatase in both groups and tissues. Gene expression of SLC25A44, which encodes a mitochondrial BCAA transporter, was increased in SkM in both groups, and gene expression of BCKDK, which encodes BCKDH kinase, was reduced in ScWAT in dysglycaemic men. Mediation analyses indicated a pronounced effect of enhanced SkM (~53%, p = 0.022), and a moderate effect of enhanced ScWAT (~18%, p = 0.018) BCAA metabolism on improved insulin sensitivity after 12 weeks of exercise, based on mRNA sequencing. In comparison, plasma concentration of BCAAs did not mediate any effect in this regard.Conclusion/interpretationPlasma BCAA concentration was largely unresponsive to long-term exercise and unrelated to exercise-induced insulin sensitivity. On the other hand, the insulin-sensitising effect of long-term exercise in men may be explained by enhanced SkM and, to a lesser degree, also by enhanced ScWAT BCAA catabolism.Graphical abstract