Left Hemiabdomen Research Articles

Plaque Morphea at Distance from Breast Cancer Radiotherapy: A Cost of the Treatment?

Introduction. Morphea is a rare dermatological disease with no known cause, characterized by persistent inflammation, collagen deposition, fibrosis, and atrophy, as well as a considerable reduction in quality of life. Case presentation. An 89-year-old female patient, with a history of arterial hypertension, right mastectomy, and radiation therapy for breast cancer 10 years before, presented for the appearance of two erythematous plaques in the right submammary groove and right flank. The plaques are well-defined, with irregular margins, and have dimensions of 10/5 cm, and 13/8 cm respectively, were infiltrated, with areas of skin retraction and visible capillary network, itchy and painful. They were observed six months before presentation, as a single hyperpigmented lesion that gradually evolved into its current appearance and was treated as a subcutaneous hematoma, without resolution. Laboratory tests showed a nonspecific inflammatory syndrome and an increase in antinuclear antibodies. By corroborating the clinical and paraclinical data, the diagnosis of plaque morphea was made, and the systemic treatment with Penicillin G 2mil IU/12h, 311nm UVB phototherapy was initiated, with favorable evolution. At the subsequent hospitalization, after noticing the increase in the size of the plaques, with their extension to the left hemiabdomen, it was decided to start treatment with Methotrexate 7.5 mg/week, with a favorable evolution and the disappearance of fibrous bands. Conclusions. Although radiotherapy may be the trigger factor of morphea, the time until the onset of the disease (9 years) is consistent with the data presented in the literature (9.4 years).

Mattox Maneuver as a Pedagogical Resource for Dissection of the Left Hemi-Abdomen

Mattox Maneuver as a Pedagogical Resource for Dissection of the Left Hemi-Abdomen

Imaging findings of familial adenomatous polyposis-associated aggressive mesenteric fibromatosis: A case report

Introduction. Aggressive fibromatosis, also known as desmoid type fibromatosis (DF) is a locally aggressive fibroblastic neoplasm that can arise anywhere in the body with no potential for metastasis and a high recurrence rate after surgical resection. Mesenteric fibromatosis are locally aggressive DF of the mesentery with a high propensity for bowel involvement. The real etiology of these tumors remains unknown, occurring sporadically or in association with familial adenomatous polyposis (FAP), as Gardner?s syndrome. Case report. A 34-year-old female patient presented with a palpable solid tumefactive mass in the left hemiabdomen. Contrast enhanced computed tomography (CT) and magnetic resonance imaging (MRI) revealed multiple massive solid tumefactions in the mesentery and in between the small bowel loops. Colonoscopy confirmed the presence of multiple sessile polyps characteristic of FAP. Tissue samples of the mesenteric mass were acquired via ultrasound guided biopsy with histopathologic confirmation of desmoid fibromatosis with imunohistochemical analysis. The risk of surgery was deemed too high at the time due to the size of the mass and proximity to mesenteric vascular structures, therefore the patient was planned for chemotherapy with a potential for further surgical reevaluation. Conclusion. Mesenteric fibromatosis is a rare neoplasm that presents with a wide range of histologic and imaging features. CT and MRI play a crucial role in evaluation and planning an optimal treatment model for patients with mesenteric fibromatosis.

Dolor abdominal autolimitado

<p>El dolor abdominal es un síntoma inespecífico y puede tener un origen sensitivo, visceral o sistémico. La evaluación del paciente con dolor abdominal puede ser un reto debido a hallazgos clínicos no concluyentes, lo que conduce a un diagnóstico incorrecto. En el presente escrito se aborda el caso de una paciente femenina de 77 años que presentaba dolor abdominal difuso, persistente, de largo tiempo de evolución, sin respuesta a tratamiento. Después de múltiples visitas médicas se detecta una masa no específica en hemiabdomen inferior izquierdo; estudios histopatológicos refieren la presencia de cáncer de endometrio.</p>

Undifferentiated pleomorphic retroperitoneal sarcoma: A case report

Introduction. Undifferentiated pleomorphic sarcoma, previously known as malignant fibrous histiocytoma, is the most common soft tissue sarcoma in adults, and retroperitoneum is the second most common location. Case Report. We present a case of a 60-year-old female patient with a painless mass in the left hemiabdomen. Computed tomography revealed a well defined retroperitoneal mass, while magnetic resonance showed a lobulated hypointense mass on T1-weighted and heterogeneous on T2-weighted images 180 x 230 x 250 mm in size, with intense peripheral enhancement. The patient underwent complete tumor excision, as well as reoperation after local recurrence. After histopathological and immunohistochemical analysis of the operating material, the diagnosis of malignant fibrous histiocytoma (giant cell type) was made. Conclusion. Radiological imaging has a limited diagnostic accuracy in undifferentiated pleomorphic sarcomas and definitive diagnosis relies on histopathological confirmation.

1538 An Unusual Presentation of Ischemic Colitis

INTRODUCTION: We present an unusual physical exam finding in ischemic colitis. CASE DESCRIPTION/METHODS: A 44 year old male with no known medical history presented to emergency department with complaint of abdominal pain and flu-like symptoms for 10 days. He had associated bloating and constipation which was minimally relieved with over the counter laxatives. There was no report of hematochezia or melena. Computed tomography of the abdomen and pelvis was notable for severe contiguous wall thickening and pericolonic fat stranding in the descending colon, sigmoid colon, and rectum. These findings were suspicious for either infectious or inflammatory colitis. There were no abnormalities in the mesenteric vasculature. The patient was discharged on an empiric course of ciprofloxacin and metronidazole, and was seen in the office two days later for follow up. On physical examination, there was an unusual finding of a tender, non-pulsating palpable mass over the left hemi-abdomen without rebound, guarding or rigidity. The patient's antibiotics were discontinued due to low suspicion for an infection. Given the finding of abdominal mass on exam, he was referred for urgent colonoscopy out of concern for colon cancer or lymphoma. On colonoscopic examination, findings were notable for altered vascularity, edema, erythema and linear erosions throughout the rectum, sigmoid colon and descending colon which were consistent with colitis. Biopsies from these sites showed edema and superficial prominence of capillary-sized vessels. The patient was given a diagnosis of colonic ischemia and he was provided with appropriate treatment. One week later on telephonic follow up, the patient reported resolution of his symptoms with plan for repeat computed tomography of the abdomen. DISCUSSION: This patient presented with an unusual finding of a palpable mass to his left hemi-abdomen in the setting of colonic ischemia. Abdominal masses on exam are most frequently due to hernias, neoplasms, infectious collections and hematomas. However, the diagnosis of colonic ischemia generally relies on history, imaging and colonoscopy. The available literature on physical exam is generally non-specific and limited to abdominal tenderness. This patient had the characteristic findings of colonic ischemia including edema, linear erosions and segmental erythema to support a diagnosis of colonic ischemia. It is suspected that his abdominal mass represented the affected colonic segments which makes this a rather unique finding for this disease.

2017 An Uncommon Etiology for Gastrointestinal Bleed in Elderly: Blue Rubber Bleb Nevus Syndrome

INTRODUCTION: Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital anomaly characterized by multiple venous malformations that can appear anywhere on the body, but most often involve the skin and gastrointestinal (GI) tract. GI bleeding usually presents in childhood or early adulthood as iron deficiency anemia. We report a case of BRBNS as a rare presentation of GI bleeding in an elderly patient with no prior history of cutaneous or GI tract involvement of the disease. CASE DESCRIPTION/METHODS: 87-year-old man with a past medical history of hypertension, coronary artery disease and atrial fibrillation (on Xarelto) was transferred to our hospital for evaluation of melena. He presented to an outside institution initially with complaints of dizziness and black tarry stools for 5 days prior to admission. He was hypotensive, labs were significant for hemoglobin (Hgb) of 5.5 g/dL and a positive stool occult blood test. Anticoagulation was discontinued. He underwent esophagogastroduodenoscopy (EGD), which showed friable mucosa in the duodenal bulb but no active source of bleeding. He received 8 units of packed red blood cells (PRBC), but his Hgb only improved to 7 g/dL. A repeat EGD was also unrevealing. He then underwent a nuclear scan, which showed a focus of bleed in left hemi-abdomen, but it was unclear if it was from the small or large bowel. On presentation to our hospital, his Hgb was 6.6 g/dL and he continued to have melena, requiring multiple PRBC transfusions. Push endoscopy revealed diffuse discontinuous multiple vascular blebs of the mucosa in the mid jejunum (Figure 1a), one of which was found bleeding (Figure 1b). Successful hemostasis was achieved with cauterization of the bleeding bleb with argon plasma coagulation (APC) (Figure 1c,d) and a hemoclip placement 2 cm distal to the lesion. Post-procedure, his Hgb remained stable above 8 g/dL throughout the hospitalization. DISCUSSION: Although BRBNS lesions can occur anywhere from mouth to anus, the small bowel is the most common site of GI tract involvement. Its presentation can vary from iron deficiency anemia to massive hemorrhage, intestinal torsion, and rupture. Some patients require lifelong iron replacement and repeated blood transfusions. Push endoscopy is the most important diagnostic modality for GI lesions. Treatment depends on the severity of lesions and can range from supportive therapies such as iron supplementation and blood transfusion to more invasive therapies such as mucosal resection, APC, sclerotherapy or bowel resection.

3217 Intussusception in a Patient With Marijuana Use: Coincidence or Possible Correlation?

INTRODUCTION: “Intussusception” is a term initially used by the Scottish surgeon, Dr. John Hunter in 1789 which means invaginating or telescoping. It is caused by any condition that disrupts the normal physiological mechanism of intestinal peristalsis. Intussusception in adults is rare with incidence of 2-3 cases per population of 1000000 annually. The most common cause of intussusception in adults is neoplasms. CASE DESCRIPTION/METHODS: 22-year-old female, with multiple past episodes of abdominal pain and vomiting, presented with one day duration of sudden onset worsening abdominal pain, vomiting and diarrhea. The stools were black but without tarry clots or frank blood. She also had four episodes of non-bilious and non-bloody emesis. Of note, she had more than one year history of extensive marijuana use. Upon presentation, her vitals were unremarkable. Physical exam was pertinent for diffuse abdominal tenderness without guarding or rebound. Initial labs were unremarkable except for an elevated lactic acid level (4.6 Mmol/L). Pregnancy test was negative. Patient received anti-emetics, proton pump inhibitor and IV fluids. She then underwent a CT scan of the abdomen and pelvis which revealed a small bowel intussusception in the left hemiabdomen. She was made NPO and subsequently underwent both upper endoscopy and colonoscopy which were normal. She was treated conservatively with bowel rest, anti-emetics and IV fluids. She gradually improved with resolution of symptoms on day four of hospital stay. Her intussusception had resolved on a follow up small bowel series. She was discharged home with outpatient Gastroenterology follow up. DISCUSSION: There is enough evidence to support that cannabis acts on several segments of the bowel. It has been demonstrated that interaction through inhibition of intrinsic cholinergic mechanisms can result in cannabis-induced inhibition of gastrointestinal motility. Fernández-Atutxa et al. and Olga et al. presented a 3 patient case series and a case report respectively with clinical presentation similar to our patient. These patients were diagnosed with intussusception with no apparent organic cause but had a history of extensive marijuana use. Our case presentation is intended to pay attention to adverse effects of cannabis in light of increasing legalization and increasing therapeutic use of cannabis and its derivatives.

An Unusual Cause of Abdominal Pain: A Telescopic View

1642_A Figure 1. Abdominal CT scan showing transverse colon invaginating into descending colon (arrow)1642_B Figure 2. Endoscopic view of rounded, ulcerated mass as lead point lesionIntroduction: Intussusception is well studied in the pediatric population but accounts for only about 1% of bowel obstructions in the adult population. Adult intussusception involving only the colon is even more rare. Case Description: A 35-year-old female presented to the emergency department with waxing and waning lower abdominal pain over a several week period. Her symptoms were initially thought to be gynecologic in origin but a transvaginal ultrasound was normal and she was discharged with outpatient follow up. She returned two weeks later with sudden worsening of the abdominal pain with associated vomiting, chills, and hematochezia. Examination revealed normal vital signs and a tender left hemiabdomen without peritoneal signs. Biochemical markers were essentially normal. Abdominal CT scan showed colocolonic intussusception involving the distal transverse and proximal descending colon with a large fat density mass as the lead point. Surgical consultation was obtained and colonoscopic exam was requested to evaluate for malignancy. Colonoscopy revealed a rounded, ulcerated, friable mass 50 cm from the anal verge that was nearly occluding the lumen, with inability to reduce the invaginated colon. Biopsy specimens resulted as fragments of ischemic/necrotic colonic mucosa with overlying acute inflammatory exudate without evidence of a neoplastic process. Symptoms persisted and the patient underwent a laparoscopic partial colectomy with primary anastomosis. Gross examination of the surgical specimen revealed an intussuscepted colon with a 6cm sessile mass containing adipose tissue with associated mucosal surface ulceration. Lipoma was confirmed on histologic examination. The patient recovered uneventfully and was discharged on post-operative day 3. Discussion: Colocolonic intussusception in adults is a rare entity and caused by benign lesions in less than 25% of these cases. In the stable patient, attempting endoscopic reduction of the intussusceptum is gaining traction in the medical literature. Colonoscopy can be used to definitively diagnose the lead point lesion and preserve viability of the effected bowel. Although our case was unsuccessful in such an attempt, colonoscopy should be considered in the future for diagnosis and reduction in cases of colocolonic intussusception.1642_C Figure 3. Gross specimen revealing in tact intussusception with large, sessile lipoma which was confirmed histologically

A Case of Familial Focal Dermal Hypoplasia: A Report of 3 Cases in Consecutive Generations

Focal dermal hypoplasia (FDH), or Goltz syndrome, is a rare multisystem disorder affecting mesodermal and ectodermal structures, with the skin, eyes, teeth, and musculoskeletal systems most commonly affected. FDH results from mutations in the PORCN gene. Ninety-five percent of cases arise from novo mutations, whereas 5% are hereditary with an X-linked dominant inheritance pattern. Here, we describe an uncommon presentation of FDH in three consecutive generations. Patient 1 is an 8-month-old female born of non-consanguineous marriage who presented with diffuse alopecia of the scalp, linear hypopigmented, atrophic papules, and plaques with peripheral hyperpigmentation on the left hemiabdomen and right lateral leg along Blaschko's lines as well as syndactyly of the right second and third toes. Skin biopsy from the abdomen showed a thin epidermis with flattened rete ridges and massive dermal edema within collagen fibers and reactive capillaries. Family history was significant for similar skin lesions and bone deformities in her mother and similar skin lesions in her grandmother. Patient 2 (patient 1’s mother) is a 17-year-old female with similar linear hypopigmented, atrophic plaques with peripheral hyperpigmentation on the abdomen and right axilla, syndactyly of the right hand, patchy alopecia of the scalp, microdontia, teeth fusion, enamel defects, verrucous papillomas in the axillae and onycholysis. Patient 3 (patient 1’s grandmother), presented with similar hypopigmented, atrophic plaques on the abdomen and left arm.

Multimodality imaging and clinicopathologic assessment of abdominal wall endometriosis: knocking down the enigma.

To review the clinical, multimodality imaging, and pathologic characteristics of abdominal wall endometriosis (AWE), the most common type of extra-pelvic endometriosis. 116 women with histopathologically confirmed extragenital endometriosis diagnosed between 2/2014 and 6/2017 were evaluated retrospectively. Of these, 26 (22.4%) were found to have AWE and 18/26 met inclusion criteria for imaging. Available imaging studies were re-reviewed by two expert radiologists. Data regarding clinical features, histopathologic findings, and management were collected through medical record review. 21 pathology-proven AWE deposits were identified by imaging in 18 women [mean age at diagnosis of 38.5years (range 31-48)]. Prior C-section was present in 15/18 (83.3%) and pelvic endometriosis in 3/18 (16.7%) patients. Patients presented with abdominal pain in 14/18 (77.8%) cases, which was cyclical in 8/14; palpable mass in 12/18 (66.7%); fluid discharge in 2/18 (11.1%); and local skin discoloration in 2/18 (11.1%). Of the 21 lesions, 15 were evaluated with US, 10 with CT, and 5 with MRI. Mean lesion dimensions were 2.5 × 2.2 × 2.6cm, and deposits were predominantly located at midline or left hemiabdomen [22/30 (73.3%)], were either stellate [15/30 (50%)] or round [15/30 (50%)] in shape, had ill-defined margins [21/30 (70%)], were heterogenous in appearance [27/30 (90%)], and involved both deep and superficial abdominal wall layers [17/30 (56.7%)]. On US, lesions were mainly isoechoic/hyperechoic [7/15 (46.7%)], and scarcely vascular [8/15 (53.3%)] with a peripheral vascular pattern [8/13 (61.5%)]. On CT, AWEs were hypervascular and homogeneous [8/10 (80%)], superiorly located to scar tissue, and on MRI lesions appeared hyperintense [4/5 (80%)] to muscle with T2 cystic and T1 hemorrhagic foci [4/5 (80%)]. In 23/27 (85.1%) original reports, there was at least one known mass prior to imaging; AWE was correctly diagnosed in only 7/23 (30.4%) cases. In those with no prior knowledge of a mass, the lesion was detected in 3/4 (75%), but AWE was only diagnosed in a single case. Median time between onset of symptoms and histopathology was 24.41 moths (IQR 15.18-47.33). AWE is a challenging clinical entity frequently diagnosed with a significant delay and easily misinterpreted despite multimodality imaging. Familiarity with its radiologic features holds the potential for positively impacting diagnosis.

Diffuse Pneumatosis Coli

A 59-year-old woman with a history of a malignant neoplasm of the tongue and right hemi-colectomy 4 years previously due to cecal volvulus presented to our Emergency Department (ED) with several days of worsening left-sided abdominal and flank pain. Her tumor had been treated 2 years prior with composite resection and chemoradiation, and she was not currently receiving any chemotherapeutic or immunomodulatory agents. She was not vomiting and was passing flatus normally, thus, her symptoms were not thought to be suggestive of bowel obstruction. Physical examination revealed a visibly uncomfortable woman with a heart rate of 79 beats/min, blood pressure of 118/74 mm Hg, respiratory rate of 18 breaths/min, and temperature of 36.5°C. Her quick sepsis-related organ failure assessment score was 0. Her abdomen was diffusely tender to palpation in the left hemi-abdomen but without signs of peritonitis. Her laboratory studies were notable for a white blood cell count of 15.7 × 103/mm3, lactic acid of 3.1 mmol/L, and serum bicarbonate of 27 mmol/L. Abdomen and pelvis computed tomography (CT) revealed innumerable foci of intramural gas throughout the large intestine, as well as extraluminal air in the left upper quadrant concerning for diffuse pneumatosis with microperforation and pneumoperitoneum (Figure 1). The small bowel and mesentery were radiographically unremarkable. A supine abdominal x-ray study demonstrated distended loops of colon and subtle gas lucencies overlying the left colon, consistent with pneumatosis (Figure 2). Figure 2Coronal computed tomography scout (A) and supine abdominal x-ray study (B) demonstrating subtle gas lucencies consistent with pneumatosis (arrows). View Large Image Figure Viewer Download Hi-res image

Gossypiboma Following Emergency Nephrectomy for Wunderlich Syndrome

We describe the imaging findings of a case of an intra-abdominal gossypiboma (retained surgical sponge) in an asymptomatic 61-year-old man who underwent an emergency nephrectomy because of a Wunderlich syndrome secondary to a renal cell carcinoma. A follow-up computed tomography was performed 4 months after the emergency surgery and showed an extraperitoneal lesion with gas bubbles and radiopaque markings in the left hemiabdomen, consistent with a retained surgical sponge ("gossypiboma" or "textiloma") in the anterior pararenal space. The patient underwent scheduled surgery for extraction of the textiloma.

Retroperitoneal liposarcoma: Case report

Introduction: Liposarcoma is a malignancy of adipose tissue, a rare tumour with an incidence of 2-3/106. Only 20% of soft-tissue-sarcomas are localized retroperitonealy, and liposarcoma accounts for 15% of them. It occurs more frequently in men (1.43:1), aging 40-70. The cause is unknown, though some emphasize trauma. It is characterized by slow growth, thus making early diagnosis difficult (absence of symptoms). Most often it metastasizes to the liver and lungs. The five-year survival ranges from 56-100% and depends primarily on histological subtype. Case report: 57 years old male, for 2 months with symptoms of abdominal pain, occasional bloating, irregular bowel movements, decreased appetite and loss of body weight of about 5 kg; developed fever 10 days earlier. He had a history of hypertension and abdominal trauma in a car accident 30 years earlier. A painful flank mass in the left hemiabdomen was palpated. Lab findings: anaemia, thrombocytosis, increased sedimentation rate and elevated C-reactive protein. Chest X-ray and abdominal ultrasound were normal. Colonoscopy showed oedematous mucosa of the sigmoid colon, partly hypertrophic with pseudopolyps, with no tumour changes. Abdominal CT showed thickened wall of the descending and sigmoid colon with a liquid collection in the area of the latter. Exploratory laparotomy showed a tumour involving the peritoneum, from the lineal flexure of the colon to the entrance into the small pelvis, retroperitoneum and omentum. Samples of peritoneum, omentum and epiploical appendices were taken. The histopathological diagnosis was a well-differentiated liposarcoma. The patient was referred to the Oncology Consilium which indicated neoadjuvant doxorubicine in IV cycles. Following the chemotherapy, the MRI of the abdomen and small pelvis was made and surgical treatment indicated. Conclusion: Retroperitoneal liposarcoma is a rare tumour mostly diagnosed at an advanced stage due to the absence of early and specific symptoms. Final diagnosis requires biopsy and patohystology. In order to ensure adequate diagnosis and treatment a multidisciplinary approach is required of a surgeon, radiologist, gastroenterologist, cardiologist, pathologist, oncologist and anaesthesiologist.

Huge Congenital Segmental Dilatation of the Sigmoid Colon in a Neonate: A "Rarity to Meet" and a "Challenge to Treat".

Only ten cases of neonatal congenital segmental dilatation (CSD) of the colon have been described so far. We present a full-term female newborn with trisomy 21, ventricular septal defect, and gross abdominal distension. Plain abdominal radiographs revealed a huge cystic lesion occupying the left hemiabdomen. Upon laparotomy on day 4 a CSD of the distal sigmoid and proximal rectum was confirmed and resected. The proximal colon was exteriorized and the distal part closed as a Hartmann pouch. Histology confirmed a huge segmental dilatation of the sigmoid without dysganglionosis or pseudodiverticula, but normal intestinal architecture. After correction of the ventricular septal defect a low rectal end-to-end anastomosis could be performed at an age of 5 months. The postoperative course was uneventful. CSD of the sigmoid colon is extremely “rare to meet” and a “challenge to treat” in the newborn period, but clinical awareness of this entity prompts pediatric surgical success.

Jejunal Diverticulitis: A Rare Cause of Left Lower Quadrant Pain

A 48-year-old female patient presented to the emergency department with increasing abdominal pain in the left hemi-abdomen, nausea and fever for two days. Clinical examination revealed mild rebound tenderness in the left lower quadrant. Laboratory tests showed leukocytosis and a raised C-Reactive Protein level. A CT-scan with oral, rectal and intravenous contrast was performed showing 2 jejunal diverticula (arrows in Fig. A & B) with important infiltration of the surrounding mesenteric fat (curved arrow in Fig. A & B) and wall thickening of the affected jejunal limb (arrow in Fig. C). The diagnosis of acute jejunal diverticulitis was made.

Idiopathic Unilateral Adrenal Hemorrhage in a 91-Year Old Woman

A 91-year old woman was referred to our hospital for evaluation of a palpable mass in the left hemiabdomen. A marked anemia was found on admission. Imaging revealed an inhomogeneous mass of the left adrenal gland with a diameter of 19 cm. Due to a lack of perfusion in contrast enhanced ultrasound and the clear delineation to neighbouring organs on CT scan, an adrenal hemorrhage was diagnosed. A further fall of hemoglobin level prompted a resection of the mass. The mass consisted of a fibrous wall surrounding hematomas of different age. A small rest of the otherwise normal adrenal gland was found adjacent to the wall. The patient fully recovered. The patient had no underlying cause for the hemorrhage such as trauma, tumor or any coagulopathy including the intake of anticoagulants. Hence, we describe a rare case of spontaneous unilateral adrenal hemorrhage in an elderly woman that was successfully treated by surgery.

Intestinal occlusion due to cryptogenic, multifocal, ulcerous, stenosing enteritis treated by laparoscopy

Background: Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is characterized by stenotic zones and multiple mucosal ulcerations in the small bowel. The diagnosis is clinical and histopathological based on the history of periodic attacks of intestinal obstruction, vomiting and abdominal pain. According to our knowledge, this is the only report of treatment of CMUSE via laparoscopy. Case Presentation: A 47-year-old man arrived to the emergency room with intense colicky pain initiated 24 hours before arrival, accompanied by nausea, gastrobiliary vomiting, constipation and inability to pass flatus. Physical examination revealed abdominal distension, generalized abdominal tenderness to palpation, peristalsis with metallic tone, no signs of peritoneal irritation, and extremities with mild edema. Laboratory exams showed hyperglycemia, hyponatremia and hypoalbuminemia. Plain abdominal X rays reveled dilated loops of small bowel and fluid levels mainly on the left hemiabdomen, suggesting mechanical ileus. No evidence of free air in the abdomen was found. Intravenous fluids and electrolyte replacement was initiated and a nasogastric tube was inserted for decompression. Medical management failed to improve the symptoms after 24 hours, so an exploratory laparotomy was performed. The affected segment was resected laparoscopically. Pathology reported multiple sites of ulceration concerning the mucosae and submucosae, myenteric plexus hypertrophy and pseudo pyloric gland metaplasia. Multiple eosinophils and neutrophils were detected. Patient was discharged from the hospital on the fifth postoperative day and started with prednisolone 30mg/day for 3 months. Three years after he has not had any other episode of intestinal obstruction. Conclusion: Diagnosis of CMUSE must be considered in cases of repeated attacks of small bowel obstruction and when stenotic areas and superficial ulcers are found. Laparoscopic surgery should be considered in patients with repeated attacks of intestinal obstruction and in whom CMUSE is suspected because it permits a diagnosis and resection of the affected segments with the advantages on the minimal invasive surgery.

Acute Appendicitis in a Patient With Intestinal Malrotation

A 49-year-old woman presented with pain in the lower abdomen and fever that had been developing over the previous 20 h. On examination, pain was observed in the left iliac fossa and hypogastrium, without guarding. Lab work showed leukocytosis with neutrophilia and elevated acute phase reactants. Abdominal ultrasound was ordered, but the appendix was not observed. Computed tomography demonstrated the small intestine in the right hemiabdomen and the large intestine in the left hemiabdomen (Fig. 1), with the pelvic cecum (2) and anterior appendix (1) showing signs that were compatible with acute appendicitis (Fig. 2). Laparoscopic appendectomy was performed. The patient progressed satisfactorily and was discharged on the following day. c i r e s p . 2 0 1 4 ; 9 2 ( 8 ) : e 4 7

Computed tomography of the abdomen of calves during the first 105 days of life: II. Liver, spleen, and small and large intestines.

Computed tomography (CT) findings of the liver, spleen and intestines of five healthy calves during six examinations in the first 105 days of life were compared with corresponding cadaver slices. The liver was located in the right hemiabdomen adjacent to the diaphragm and right abdominal wall. The caudal vena cava was seen dorsomedially and the portal vein further ventrally. The umbilical vein was seen running from the navel to the liver in all calves in the first scan and in four calves in the second scan. The spleen ran dorsoventrally adjacent to the costal part of the left abdominal wall and appeared sickle-shaped on transverse images. Differentiation of small and large intestines was only possible when the former contained fluid content and the latter gaseous content. The small intestine was in the left hemiabdomen dorsal to the abomasum and caudodorsal to the rumen at the first two examinations. Growth of the forestomachs caused displacement of the small intestine to the right and toward the ventral abdomen caudal to the liver and adjacent to the right abdominal wall. The large intestine was located caudodorsally, and the typical features of the spiral colon were apparent in the dorsal plane. The location of the caecum varied from dorsal to the spiral colon to adjacent to the right abdominal wall with the apex always pointing caudally. The rectum was easily identified in the pelvic region. The size, volume and density of the described organs throughout the study are shown in several tables.