Left Lower Quadrant Abdominal Pain Research Articles

Intussusception: An Initial Presentation of Colorectal Malignancy at Young Age

Introduction: Intussusception of the bowel is defined as the telescoping of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment and is found frequently in children. It is less common in adults. Most of the intussusceptions in adults are caused by a definite underlying disorder such as neoplasm or by postoperative condition. We report a similar case in a young adult presenting as intussusception with no family history of colon cancer. Case report: A 26 year old male with no family history of colon cancer presented with acute worsening of left lower quadrant abdominal pain that he was experiencing for three months. It was associated with diarrhea and constipation. His vitals were stable on presentation. Examination showed minimal tenderness in the left lower quadrant with no palpable mass. Labs were unremarkable except for mild microcytic hypochromic anemia. Abdominal CT scan showed intussusception along with regional pericolic lymph nodes. He was managed conservatively initially, as per surgical team recommendations. Subsequently, colonoscopy was performed which showed a 5 cm ulcerated, partially obstructing mass in the descending colon. Histopathology results showed tubulovillous adenoma with high grade dysplasia. CEA level was 9.6 ng/ml. Patient underwent laparoscopic left hemicolectomy later and biopsy results showed moderately differentiated invasive adenocarcinoma, mucinous type, with no lymphovascular or perineural invasion. Patient is now scheduled to follow up medical oncology for further management. Discussion: The interesting fact about this case is the diagnosis of colon cancer at very young age with no previous family history of colon cancer, which presented as intussusception. Adult intussusception occurs relatively rarely; accounting for 5% of all cases of intussusceptions. A specific lead point is identified in more than 90 % of cases while 10% cases are idiopathic. Malignant lesions account for up to 30 % of cases in small intestine and 66 % of the cases in the large intestine. Abdominal CT scan is diagnostic modality of choice in these patients. It may also help in defining the location, the nature of the mass and it may help staging the patient with suspected malignancy causing the intussusception. Intussusception associated with malignancy should be managed by multispecialty collaboration.Figure 1Figure 2Figure 3

Spontaneous rupture of peritoneal seeding hepatocellular carcinoma: Report of two cases

Abstract Background Non-traumatic hemoperitoneum is a potentially life threatening condition that requires prompt diagnosis and intervention in the emergency department (ED). There are many causes of non-traumatic hemoperitoneum, but spontaneous rupture of a peritoneal seeding tumor is rare. Case report We describe two cases of spontaneous rupture of a peritoneal seeding hepatocellular carcinoma (HCC), following spontaneous rupture of HCC in the ED. Two patients, with a history of ruptured HCC presented with acute left upper quadrant and right lower quadrant abdominal pain. Vital signs were stable, and the diagnosis was made by contrast-enhanced computed tomography scan of abdomen. The patients survived because of early diagnosis and surgical intervention. Conclusion This report highlights that spontaneous rupture of peritoneal seeding HCC can occur after spontaneous rupture of HCC. Emergency physicians should be aware of this rare complication, particularly in Asian countries. Surgical intervention is the appropriate choice for definitive treatment.

A Rare Case of Symptomatic Mesenteric Panniculitis

Mesenteric panniculitis is an uncommon inflammatory disorder of the intestinal mesentery belonging to a spectrum of idiopathic disorders termed sclerosing mesenteritis. Clinical presentation ranges widely from asymptomatic to bowel obstruction. We present a rare case of symptomatic mesenteric panniculitis. A 59 y/o female with a history of ischemic colitis presented to the ED with progressive epigastric and left lower quadrant abdominal pain, nausea, and constipation. Physical exam revealed a distended, diffusely tender abdomen with bloodwork showing a WBC of 18,000 cells/microL. CT scan showed focal dilation of small bowel without discrete obstruction. EGD and gastric emptying study were unremarkable. Given her persistent abdominal pain a follow up MR enterography was performed which showed mesenteric stranding (Figure 1) and prominent lymph nodes in the right and left lower quadrants consistent with mesenteric panniculitis (Figure 2). The patient was treated with prednisone and Tamoxifen with resolution of symptoms. PET-CT and colonoscopy were negative for concomitant malignancy. Tumor markers including CEA, CA 19-9, and AFP were within normal limits.Figure 1Figure 2Mesenteric panniculitis is a chronic, nonspecific fibrosing disorder of the adipose tissue of the intestinal mesentery. It can occur independently or in association with malignancy, vasculitis, or autoimmune disorders. While the majority of cases are asymptomatic, symptoms may include abdominal pain and asthenia. Obstructive symptoms and CT features of small bowel dilatation, like our case, are rare. While biopsy was previously required for diagnosis, CT and MRI are now acceptable modalities for diagnosis. Work up should include exclusion of associated malignancy. Although there is no standard therapy, treatment with steroids, Cyclophosphamide, and Tamoxifen among others, have been used. Surgical resection is performed in cases of intestinal obstruction. In conclusion, mesenteric panniculitis is a rare clinical entity that can occur independently or in association with other disorders. Diagnosis can be challenging, but features on cross sectional imaging can be highly suggestive of the disease. Associated malignancy should be excluded. Treatment with antiinflammatory and immunosuppressive agents can be successful with an overall good prognosis and rare recurrence.

Primary Pulmonary Choriocarcinoma

We present a case of a 25-year-old Hispanic woman who presented to emergency department with chief complaint of left lower quadrant abdominal pain. Initial workup revealed positive pregnancy test. Serum human chorionic gonadotropin was 36,478 (normal range, 0 to 8.0) IU/mL. She underwent diagnostic laparoscopy with dilatation and curettage, which did not reveal any evidence of intrauterine or extrauterine pregnancy. Chest and abdomen radiographic findings were significant for a heterogenously enhancing 2.2×1.7×1.6 cm nodule in superior segment of the right lower lobe of the lung and a large perinephric hematoma. We performed radial endobronchial ultrasound-guided transbronchial biopsies of the right lower lobe lesion. Pathologic specimen revealed choriocarcinoma.

Elevated Lipase Without Pancreatitis in Infectious Colitis

BackgroundAn elevated lipase typically confirms the diagnosis of pancreatitis. Elevated lipase may be associated with other disorders, typically with some influence on the pancreas. The differential is more limited than elevated amylase secondary to the mostly unique production of lipase in pancreatic acinar cells. Elevated lipase has been reported in patients with inflammatory bowel disease, but not previously reported in infectious colitis. Case ReportA 65-year-old woman presented to the emergency department with left lower quadrant abdominal pain radiating to her left flank worsening over 2 days. She denied epigastric pain. She had occasional nausea and occasional nonbilious and nonbloody emesis, and also reported diarrhea and weight loss over the preceding months. Laboratory values were largely unremarkable except for a grossly elevated lipase level. Computed tomography scan of her abdomen was performed and revealed findings consistent with infectious colitis, without signs of pancreatic inflammation or other findings associated with pancreatitis. She was admitted to the hospital and treated for infectious colitis with antibiotics and improved over 2 days, and was subsequently discharged for follow-up with her gastroenterologist. This is the first reported case of elevated lipase without pancreatitis associated with infectious colitis. Why should an emergency physician be aware of this?Emergency physicians should be aware of other potential causes of elevated lipase and not assume that all cases of elevated lipase are associated with pancreatitis. This may possibly avoid unnecessary admission in situations that are not clearly pancreatitis.

An Unusual Case of Lymphocytic Colitis in the Setting of Methamphetamine Use and Rectal Chlamydia Infection

Introduction: Worldwide, methamphetamine (i.e., crystal meth) abuse is rapidly increasing. Although inhalation and intravenous use is commonplace, rectal administration of this drug has become an emerging mode of abuse, with a few case reports of methamphetamine-induced ischemic colitis. We present the case of a 33-year-old homosexual man with no significant past medical history who presented with hematochezia, crampy abdominal pain, and lightheadedness for 2 days. The patient was in his usual state of health until 1 week prior to admission when he engaged in inhalational and rectal methamphetamine use, as well as receptive anal intercourse on multiple occasions for 4 consecutive days. Four days prior to admission, the patient experienced increasing fatigue. The day prior to admission, the patient passed soft brown stool mixed with a few milliliters of bright red blood per rectum. The patient then had numerous episodes of bloody diarrhea associated with crampy left lower quadrant abdominal pain. He denied melena or hematemesis. Initial labs were significant for WBC 13.8 (bands 43%), INR 1.5, and liver function tests within normal limits. A rapid HIV, RPR, stool culture, Clostridium difficile PCR, and hepatitis A/B/C panel were all negative. A rectal swab was positive for chlamydia. A CT scan showed colonic wall thickening from the splenic flexure distally to the rectum with pericolonic fat stranding. A flexible sigmoidoscopy demonstrated diffuse moderate inflammation characterized by erythema and loss of vascularity with scattered superficial ulcerations from the rectum extending approximately 50 cm proximally. Colonic and rectal biopsies revealed diffuse injury to the surface epithelium with a background of increased stromal and intraepithelial lymphocytes. The cause of this lymphocytic-predominant colitis is unclear. While lymphogranuloma venereum (LGV) can cause a proctosigmoiditis that can mimic inflammatory bowel disease and cause lymphoplasmacytic infiltrates, we cannot rule out methamphetamine as a potential contributor to the colitis. The patient is currently undergoing treatment with doxycycline and if he remains symptomatic after a sufficient course, budesonide therapy will be considered. It is important for practitioners to suspect LGV in patients with high-risk sexual behavior and to be aware of the increase in methamphetamine abuse and the ever-changing modalities of its administration as both can present as endoscopically abnormal colonic mucosa.

Spontaneous Rectal Passage of a Colonic Angiolipoma After Colonoscopy With Forceps Biopsy

A 75-year-old man presented with a week-long history of constipation and left lower quadrant abdominal pain that was preceded by a week of diarrhea and scant bright red blood per rectum. Initial work-up demonstrated a normal physical exam, complete blood count, and comprehensive metabolic panel. Three view abdominal x-ray showed mild colonic dilatation. Subsequent computed tomography scan of the abdomen showed a 4.3 × 3.1 × 4.9 cm, well-defined, heterogeneous mass projecting into the lumen of the descending colon (Figure A, arrow).

Case 1: A 16-year-old female with left lower-quadrant abdominal pain

A previously healthy 16-year-old female presented to the emergency department with a four-day history of vomiting, diarrhea and left lower-quadrant abdominal pain. Clinically, the patient exhibited signs of abdominal distention, with a fluid shift suggestive of ascites. Bowel sounds were diminished, her leukocyte count was elevated and radiographs of the abdomen showed dilated small-bowel loops compatible with a bowel obstruction. An ultrasound showed a large volume of peritoneal fluid without a visualized appendix. An urgent computed tomography scan suggested small-bowel obstruction. The patient underwent an exploratory laparoscopy, which revealed a large volume of purulent fluid in the pelvis, right and left lower colic gutters, as well as above the liver. The small bowel was tethered together with interloop abscesses. The small bowel was examined twice, distally to proximally, with no evidence of adhesive bowel obstruction. The appendix appeared normal. The uterus, fallopian tubes and ovaries all appeared inflamed but no tubo-ovarian abscess was present. The abdomen was irrigated copiously with 4 L of saline. Postoperatively, the patient was started on ampicillin, gentamicin and metronidazole. The preliminary blood culture identified Gram-positive clusters, and the antibiotics were switched to meropenem and vancomycin while awaiting identification of the organism.

Efficacy of preoperative computed tomography imaging to reduce negative appendectomies in patients undergoing surgery for left lower quadrant abdominal pain

Clinical assessment of acute appendicitis can be challenging due to atypical presentation. Computed-tomography can reduce negative appendectomies but not without adverse effects. We report our experience with preoperative CT-scan in patients with suspected acute appendicitis. During 3-years, 257 adult patients underwent appendectomy. We retrospectively reviewed clinical information, CT-scans, histological data. Patients were divided in four groups: Group I: low clinical probability without CT-scan; Group II: low clinical probability with CT-scan; Group III: high clinical probability without CT-scan; Group IV: high clinical probability with CT-scan. Negative appendectomies were determined from histological examination. Negative appendectomy rate was compared between groups of the same clinical probability differing on whether a pre-operative CT scan was performed or not (Group I vs II, Group III vs IV). Groups I,II,III,IV included 12.4%, 18.2%, 54.5% and 14.8% of patients, respectively. The corresponding negative appendectomy rates were 18.7%, 4.3%, 4.2% and 2.6%. Odds ratio of negative appendectomy for patients without CT-scan was 5.2 (95% CI: 1.2-27.7) when there was low clinical probability and 1.6 (95% CI: 0.2-14.2) for high clinical probability. Patients with low clinical probability of acute appendicitis benefit the most from preoperative CT while this does not apply to patients with high clinical probability.

Spectrum of Non-Typhoidal <i>Salmonella</i> Infections among Immunocompetent Individuals

Non-typhoidal salmonellosis has emerged as an invasive infection in industrialized countries. Bacteremia and pleuropulmonary involvement usually occur in the setting of chronic illnesses such as diabetes, malignancies and HIV. We present three cases of non-typhoidal salmonellosis in immunocompetent patients presenting over a year period. A 66-year-old female presented with septic shock. She was started on vancomycin, doripenem and ciprofloxacin. Her blood cultures grew Salmonella enteridis that was also isolated from her urine and bronchoalveolar lavage fluid. Stool cultures were negative for Salmonella species. She had no epidemiologic risk factors for invasive Salmonella infection. Her immunodeficiency workup was negative. CT scan abdomen was unremarkable. She became hemodynamically stable and completed a two week course of Ceftriaxone without complications. A 58-year-old female presented with sub-acute onset of fever and dyspnea. CT chest showed bilateral pleural effusions. Left sided thoracentesis revealed purulent fluid consistent with empyema. Pleural fluid cultures grew Salmonella Group D. Blood, sputum and stool cultures remained negative. She denied consumption of raw eggs or exposure to pets, farm animals or reptiles. She was treated with Ceftriaxone for two weeks along with pigtail catheter drainage. Her immunodeficiency workup was negative. A 62-year-old man presented with acute left lower quadrant abdominal pain. CT Abdomen revealed a focal abnormality in abdominal aorta consistent with mycotic aneurysm. Blood cultures grew Salmonella Group D resistant to cephalosporins and bactrim, hence treatment with Meropenem was started. Subsequent blood, respiratory tract, urine and stool cultures remained negative. Due to high risk of perioperative complications, it was decided to follow the mycotic aneurysm expectantly. Antibiotics were deescalated to six weeks of Ertapenem followed by long term quinolone prophylaxis. He also did not have any epidemiologic risk factors for salmonellosis and his immunodeficiency workup was negative. These cases highlight the pathogenesis of this invasive organism that is transmitted though food borne route and causes bacteremic seeding of various sites such as lungs and pleura. It is extremely important to consider this organism in patients presenting with gram negative bacteremia leading to septic shock as well as endovascular infections.

Jejunal diverticulitis: An unusual cause of left lower quadrant abdominal pain in a young female

Acquired small bowel diverticulitis is an uncommon condition, predominantly affecting elderly population. It is exceedingly rare in young adults. Such a rare case of jejunal diverticulitis in a young female is presented here. Due to the nonspecific clinical presentation, accurate clinical diagnosis of this condition is difficult. Computed tomography (CT) scan provides early and specific diagnosis, thus facilitating successful nonsurgical treatment.

Crohnʼs Disease? Wait and CMV

Purpose: Cytomegaolvirus (CMV) is a double-stranded DNA virus member of the herpes family. The T-cell-mediated immune system is responsible for host infection response and surveillance. Primary infection usually manifests as mononucleosis, or has nonspecific symptoms. Severe organ involvement is uncommon in the immunocompetent. A 21-year-old male was referred to GI clinic after two emergency room visits for abdominal pain, diarrhea, and scant hematochezia. He was previously diagnosed with hemorrhoids and anal fissure, treated with supportive care. His history and physical was consistent with colitis/proctitis, with left lower quadrant abdominal pain, anal fissure, and severe perianal tenderness, confirmed with CT imaging. He was admitted for further evaluation, and underwent flexible sigmoidoscopy with patchy areas of edematous, erythematous, friable mucosa with areas of ulceration, and granulation visually similar to Crohn's. Treatment was withheld pending biopsies, which were suggestive of reactive viral process. CMV immunohistochemical stains demonstrated cytoclasmic inclusion bodies, and serum CMV antibody and PCR testing were positive. Treatment with ganciclovir was initiated with slow improvement. He subsequently was lost to follow-up until a subsequent emergency room visit with positive tests for chlamydia and gonorrhoeae. Cytomegalovirus exposure is highly prevalent worldwide, with an estimated 40-100% of middle-age adults having serologic evidence of exposure. Rarely does infection in the immunocompetent require hospitalization. Severe infection most commonly causes hepatitis, colitis, encephalopathy, or pneumonia, with multiorgan involvement carrying poorer prognosis. Severe infection should prompt evaluation for an immunecompromised state while initiating antiviral therapy. This patient was sexually active with both genders, and engaged in anoreceptive intercourse. STD tests were preformed and were negative, to include HIV PCR to exlude acute infection. Immunglobulin quantification testing was normal. Inflammatory bowel disease (IBD) also commonly presents in this age group with similar symptoms of colitis. CMV DNA has been demonstrated to be present in up to 66% of Crohn's disease biopsies; however, it did not correlate to disease activity. In ulcerative colitis, seropositive prevalence was 72% in one study, again without correlation to symptoms. A relationship between CMV and IBD has not been definitively demonstrated. Consideration should be made for delaying treatment in new cases of IBD until biopsies confirmation and exclusion of infection. Immunosuppressant therapy impairs host defenses, and glucocorticoid therapy has not conclusively been shown to improve outcomes in CMV colitis.

Recurrent Clostridium difficile Colitis in a Patient with Concurrent Diverticulitis

Background:Clostridium difficile infection (CDI) and diverticulitis both cause inflammation of the colon and mimic each other radiographically. Distinguishing between the two entities is essential, as the treatment for diverticulitis (fluoroquinolone or cephalosporin, in addition to an antibiotic with anaerobic activity) can be a harbinger for CDI. Although rare, both diseases can present simultaneously, making diagnosis and treatment difficult. Case Presentation: A 76-year-old man with a history of recurrent diverticulitis subsequently developed CDI and was referred to us with recurrent symptomatic colitis. In May and November, 2011, he developed left lower quadrant abdominal pain and was treated with ciprofloxacin and metronidazole for 10 days with resolution of symptoms each time. Another episode occurred in December, 2011, but he now developed bloody, watery diarrhea. His stool C. difficile toxin assay was positive, and he was treated with metronidazole for two weeks with resolution of his diarrhea. Three months later, he again developed watery diarrhea, and his stool was positive for C. difficile. He responded to treatment with oral vancomycin followed by a prolonged taper, but within a week of discontinuing the taper, his diarrhea returned and he became dehydrated, requiring hospitalization. His WBC was 15.6 x 10ˆ3/μl. CT scan (June 4, 2012) showed thickening of the distal transverse, descending, and sigmoid colon. Given these findings, he was treated for recurrent sigmoid diverticulitis (ciprofloxacin and metronidazole) and CDI (fidaxomicin followed by a vancomycin taper). Review of his follow-up abdominal CT (June 29, 2012) showed resolution of colitis in the transverse and descending colon, but residual abnormalities in the sigmoid colon. As his symptoms resolved, he continued only a suppressive dose of vancomycin (125 mg once daily). He again became symptomatic (July, 2012) with bloody stools, abdominal cramps, and fever, and was treated for both entities. Although his vancomycin regimen was empirically increased to 250 mg QID, his stool C. difficile assay was negative, and this episode likely represented simple diverticulitis. The patient successfully underwent resection of the sigmoid colon two months later and has had no further symptoms. Conclusion: Management of recurrent CDI and diverticulitis becomes difficult as the antibiotics used to treat the latter are often the culprit in the development of the former. Prior studies suggest that patients with diverticulosis who develop CDI are more prone to CDI, as the diverticula themselves serve as a reservoir for C. difficile spores. In patients with recurrent CDI and concurrent diverticulitis, surgical resection of the latter should be considered.

The Case Files

A 57-year-old man with a past medical history of prostate cancer presented to the emergency department with a one-day history of fever, chills, and left lower quadrant abdominal pain. His temperature was 102.1°F, and his abdomen was moderately tender in the left lower quadrant with no associated peritoneal signs. The patient denied any chest pain, shortness of breath, diarrhea, constipation, or urinary symptoms including dysuria, increased frequency, or urgency. An acute abdominal series was obtained in the emergency department, and it incidentally revealed embolization of the patient's prostatic brachytherapy seed implants to his lungs. Radioactive seed migration from prostate brachytherapy was first described by Steinfield et al in 1991, and is well known in radiation oncology. Numerous reports of radioactive seed migration now exist in the literature. Pulmonary embolization of seed implants has an estimated incidence of two to 21.8 percent. The primary adverse effect of seed migration is the potential reduction in radiation dose to the prostate, potentially affecting cancer treatment. No adverse effects related to the lung have been reported, and most believe that pulmonary embolization of prostatic brachytherapy seed implants is not harmful to lung function or structure.Figure: PA chest x-ray showing prostatic brachy-therapy seeds embolized into the lungs.Other case reports have described seed migration to the left renal vein, left renal artery, vertebral venous plexus, liver, and heart. The patient in this case denied any respiratory complaints such as cough, shortness of breath, chest pain, or hemoptysis, so the focus of his medical treatment was centered on his abdominal pain. The patient underwent a CT scan of the abdomen and pelvis, which revealed acute diverticulitis. He received intravenous antibiotics, was admitted to the hospital, and was discharged several days later after an uncomplicated hospital stay.Figure: CT chest scan showing prostatic brachy-therapy seeds embolized into the lungs.Figure: KUB showing a non-obstructive bowel gas pattern.Figure: Bladder shot showing brachytherapy seed implants in the prostate.

5-ASA Induced Recurrent Myopericarditis and Cardiac Tamponade in a Patient with Ulcerative Colitis

A 20-year-old woman with recently diagnosed moderate left-sided ulcerative colitis (UC) presented to the emergency department (ED) for chest pain. Two months earlier, she had been evaluated in gastroenterology clinic for bloody diarrhea and crampy left lower quadrant abdominal pain. Stool tests for infectious causes were negative. Colonoscopy demonstrated diffuse mucosal erythema, linear ulcerations, and friability that extended continuously from the rectum to the descending colon (Fig. 1), histologically reported as acute and chronic colitis with crypt architectural distortion, consistent with inflammatory bowel disease. No granulomas or viral inclusion bodies were seen. Institution of sulfasalazine 500 mg four times daily and mesalamine enemas significantly improved her symptoms. Three weeks later, she presented to the ED with pleuritic chest pain, aggravated by lying flat and relieved by leaning forward. She denied nausea, vomiting, coryza, or cough. She was afebrile, with a heart rate 116 beats per minute and blood pressure 102/67 mmHg. Physical exam was notable for a friction rub heard loudest over the left sternal border, mild epigastric tenderness, and 1? pitting edema to the mid-shin. Laboratory examination revealed leukocytosis with neutrophilia (WBC 16.8 k/ll, 82.8 % neutrophils), elevated troponin, creatine kinase-myocardial band (CK-MB), erythrocyte sedimentation rate (ESR), and C-reactive protein. ECG revealed diffuse ST elevation. Echocardiography revealed a small pericardial effusion with normal systolic function (Fig. 2), which was also noted in the CT angiogram report, with no evidence of pulmonary embolism or other chest pathology. The patient was diagnosed with acute myopericarditis. Direct fluorescent antibody test for respiratory viruses, blood cultures, HIV antibody screen, PPD, and autoantibodies (including anti-nuclear antibody, anti-double-stranded DNA, and others) were all negative. Although viral myopericarditis could not definitively be excluded (since not all implicated viruses can be tested for), the main concern was for a reaction to sulfasalazine or, less likely, rectal mesalamine. Sulfasalazine was thus discontinued, mesalamine enemas were switched to hydrocortisone enemas, and she was treated with ibuprofen and colchicine, with symptom resolution. Low-dose balsalazide was then cautiously initiated. Five days later, the patient returned with recurrent severe pleuritic chest pain. She was hypotensive (85/52 mmHg) and tachycardic (117 bpm). Her ECG showed diffuse T wave flattening without electrical alternans. Bedside echocardiogram revealed a large pericardial effusion with hemodynamic compromise consistent with cardiac tamponade (Fig. 2). She underwent emergent pericardiocentesis with drainage of 300 ml of serosanguinous fluid. Fluid analysis and cultures were unrevealing. She was again treated with ibuprofen and colchicine, with discontinuation of the balsalazide, accompanied by marked improvement of her chest pain. Hydrocortisone enemas were prescribed with a plan for immunomodulator I. Sonu R. Wong M. E. Rothenberg Department of Medicine, Stanford University Medical Center, Stanford, CA, USA

Large benign submucosal lipoma presented with descending colonic intussusception in an adult

Patient: Female, 34Final Diagnosis: Lipoma of the large intestineSymptoms: Abdominal pain • bloating • blood in stool • constipation • lose of appetite • nauseaMedication: —Clinical Procedure: —Specialty: SurgeryObjective:Rare diseaseBackground:Lipoma of the large intestine is rare, account for only 5% of all gastrointestinal tumors. Lipomas are usually asymptomatic but rarely may cause bleeding, obstruction and intussusception. We present a case of a giant colonic lipoma causing descending-colonic intussusception.Case Report:34 yo F presented with the intermittent left lower quadrant abdominal pain for 3 weeks. The pain initially was associated with bloating and constipation and for the last several days frank blood in stool, nausea and decreased appetite. CT scan of the abdomen revealed descending colonic obstruction by a 5.3 cm colonic lipomatous mass with resultant intussusception. Patient initially underwent colonoscopy that revealed polypoid lesion at 3–40 similar to lipoma with intussusception that was reduced. Patient subsequently underwent laparoscopic segmental left colectomy for the descending colonic intussusception due to large colonic lipomatous mass. Pathology confirmed the histology of lipoma.Conclusions:Adult bowel intussusception is a rare but challenging condition to diagnose in a timely manner. Preoperative diagnosis is usually missed or delayed because of nonspecific and often subacute symptoms. Lipoma is a rare cause of the intussusception. A high index of suspicion and appropriate investigations (abdominal ultrasound, CT scan and colonoscopy) can result in prompt diagnosis. Lipoma of the large intestine is very rare. Submucosal lipomas are usually asymptomatic but may cause bleeding, obstruction, intussusception, or abdominal pain. Accurate preoperative diagnosis is difficult and lipoma is often mistaken for adenomatous polyp or carcinoma. Treatment usually requires formal resection of the involved bowel segment due to high suspicion for malignancy and subsequent complications due to obstruction.

Isolated Fallopian Tube Torsion: A Case Report and Review of Literature

Isolated fallopian tube torsion is a rare cause of pelvic pain in female patients. We present the case of a 10 year old female without significant past medical history who presented with acute left lower quadrant abdominal pain. A CT scan of the abdomen/pelvis showed a dilated, tortuous, fluid-filled structure in the left adnexal region which was ultimately diagnosed as a torsed fallopian tube. Subsequent trans abdominal ultrasound examination documented the fallopian tube’s lack of vascularity with color Doppler and demonstrated thickened, edematous walls and longitudinal folds. The ipsilateral ovary maintained normal vascularity and was unremarkable. The patient underwent laparoscopic salpingectomy, and pathologic examination of the specimen confirmed hemorrhagic fallopian tube necrosis. The patient recovered without complication, and has not experienced any pain recurrence since the procedure.

Cystic adnexal mass in a 16-year-old female: Ovarian pathology or complication of a Müllerian anomaly?

Patient: Female, 16Final Diagnosis: Pelvic massSymptoms: NoneMedication: NoneClinical Procedure: CT • MRISpecialty: Diagnostic radiology • pediatricsObjective:Unusual presentation of unknown etiology, Rare disease, Mistake in diagnosisBackground:Müllerian anomalies encompass a wide variety of malformations in the female genital tract, usually associated with renal and anorectal malformations. Of these anomalies, approximately 11% are uterus didelphys, which occurs when midline fusion of the müllerian ducts is arrested to a variable extent.Case Report:We report the case of a 16-year-old female with uterine didelphys, jejunal malrotation, hematometra, hematosalpinx, and bilateral subcentimeter homogenous circular cystic-like renal lesions, who initially presented with left lower quadrant abdominal pain, non-bloody vomiting, and a history of irregular menstrual periods. Initial CT was confusing for an adnexal cystic mass, but further imaging disclosed the above müllerian anomalies.Conclusions:Müllerian anomalies may mimic other, more common, adnexal lesions; thus, adequate evaluation of suspicious cystic adnexal masses with multiple and advanced imaging modalities such as MRI is essential for adequate diagnosis and management.

Endovascular Repair of a Para-Anastomotic Pseudoaneurysm After Renal Autotransplantation: An Alternative to Open Reconstruction

Renal artery anastomotic pseudoaneurysms are rare after renal transplantation. The etiology tends to be technical, infectious, or degenerative, and repair is difficult with a high postsurgical complication rate. We report the first case of a complex autotransplant renal artery pseudoaneurysm repaired with kissing covered stents. A 52-year-old woman presented with severe left lower quadrant abdominal pain 6 years after a renal autotransplant for ureteral stenosis and recurrent pyelonephritis. A computed tomographic angiography (CTA) scan revealed a bilobed aneurysm arising at the anastomosis between the renal and common iliac arteries. Kissing covered stents were placed within the common iliac artery proximally and extending into the transplant renal artery and external iliac artery. Postdeployment angiography confirmed complete exclusion of the pseudoaneurysm and excellent flow into the transplant kidney and left lower extremity. A follow-up CTA scan at 1 month revealed continued stent-graft patency and complete exclusion of the pseudoaneurysm. An endovascular approach to transplant anastomotic pseduoaneurysms using kissing covered stents is a viable option to exclude aneurysmal changes and preserve flow to the transplanted organ in carefully selected patients.

Spectrum of Nontyphoidal Salmonella Infections Among Immunocompetent Individuals

SESSION TYPE: Infectious Disease Case Report Posters II