Lower Quadrant Research Articles

Inflamed Mesenteric Pseudocyst Associated with Meckel’s Diverticulitis: Cause or Consequence

Introduction: Mesenteric pseudocyst describes an abdominal mass that appears on small bowel mesentery or mesocolon, or at any part of the abdomen and retroperitoneum. This paper aims to emphasize the non-specific clinical appearance and highlight Meckel’s diverticulitis as a potential cause of the development of pseudocyst. Case Report: A 26-year-old male with a palpable mass in the right upper abdominal quadrant and an increased body temperature of 38.3∘C was admitted for further medical investigation. Computed tomography (CT) presented a cystic mass with a diameter of 5.5 cm, and emergency laparotomy was performed. Wedge resection of pathologic findings of small bowel, its mesenterium, and the cyst mass associated with nearby Meckel’s diverticulum was performed. Discussion: Meckel’s diverticulum can be considered as a risk for developing mesenteric pseudocyst, because of its frequent exacerbation of chronic inflammation. This report adds to the limited literature on the association between Meckel’s diverticulum and mesenteric pseudocysts, providing valuable insights that can guide future clinical evaluations and surgical interventions. Early and accurate diagnosis, aided by imaging techniques such as CT and magnetic resonance imaging (MRI), is essential for effective management. This case highlights the potential link between chronic inflammation in Meckel’s diverticulum and the formation of mesenteric pseudocysts. Conclusion: This case highlights the need to consider Meckel’s diverticulitis in patients with mesenteric pseudocysts, suggesting a possible pathophysiological link between them. Surgical resection is recommended for effective management.

An unexpected surprise: splenic volvulus

BackgroundSplenic volvulus is a rare cause of acute and chronic abdominal pain. This condition is determined by an insufficiency or absence of the ligamentous attachments, a condition known as “wandering spleen” that causes a hypermobility of the spleen. Wandering spleen could be congenital or acquired and is more frequent in women of reproductive age and in children. Symptoms may remain limited or absent for long periods of time, but complications can occur due to the torsion of the splenic vascular pedicle, resulting in symptoms ranging from an incidental finding to an acute abdomen derived from ischemic necrosis of the spleen.Case presentationA 19-year-old male, admitted for abdominal pain and general discomfort. Considering the objective examination, further diagnostic tests were requested. Computed tomography (CT) revealed a chronic venous thrombosis of the splenic vein, hypoperfusion and malposition of the spleen, peritoneal effusion and stretching of structures in the left upper abdominal quadrant. These are strongly suspicious signs of splenic volvulus.ConclusionThe diagnosis of this rare condition can be challenging because of the variability of its symptoms and its capacity of mimicking other pathologies. Suggestive signs should be recognized in order to ensure a timely diagnosis and to choose the optimal strategy of treatment.

EGS SO05 - Improving the Flow of Patients Attending Surgical Assessment Unit: Introduction of Ambulatory USS Slots - Closed Loop Audit

Abstract Background Modern emergency surgical service recognises that a significant proportion of patients presenting with acute abdomen can be diagnosed and treated in the ambulatory fashion. However, this approach requires multidisciplinary cooperation between the general surgery team and radiology department. We aimed to assess and improve the flow of patients presenting to Surgical Assessment Unit (SAU) with complaints of right iliac fossa (RIF) and right upper quadrant (RUQ) pain. Method We performed a retrospective analysis of all ambulatory patients returning to SAU of a District General Hospital with RUQ and RIF pain in January 2023. We measured the waiting time between the arrival to SAU and the time of USS. We presented the results in a local meeting and negotiated the introduction of two daily USS slots for SAU patients. We re-assessed the impact of the USS slots on waiting times in July 2023. Results In January 2023, 13 patients returned to SAU for USS. The minimum waiting time for this cohort was 59 minutes and the maximum waiting time was 3 hours and 39 minutes. The median was 2 hours and 15 minutes. In July 2023, 18 patients returned to SAU for USS. The minimum waiting time for this cohort was 4 minutes and the maximum waiting time was 2 hours and 20 minutes. The median was 1 hour and 5 minutes. There was an average reduction of 1 hour and 10 minutes in waiting time for USS. Conclusion The introduction of two USS slots per day for patients returning to SAU with RUQ and RIF pain resulted in a 48% reduction in waiting times. This improved the flow of patients, sped up the diagnosis and timely access to treatment, as well as significantly improved patients experience and satisfaction. We would recommend close co-operation between general surgery and radiology to allow timely access to imaging for patients presenting with acute abdomen to SAU.

Abstract A049: Peritoneal tumor DNA as a prognostic biomarker in locally advanced gastroesophageal cancer: A pilot prospective cohort study

Abstract Background: Gastroesophageal cancers commonly spread to the peritoneum. Peritoneal disease significantly alters patient prognosis and treatment-intent. Currently, peritoneal lavage cytology (PLC) is the method of choice for detecting peritoneal micro-metastasis within the peritoneum. Despite its pervasive use, PLC has a variable sensitivity of 10% - 80% in detecting peritoneal micro-metastasis in gastroesophageal cancers. Peritoneal tumor DNA (ptDNA) is tumor-derived DNA detectable in peritoneal lavage fluid. ptDNA-positivity may indicate peritoneal micro- metastasis and may be more sensitive than PLC in staging the peritoneum and predicting disease- free survival (DFS) and overall survival (OS). We aimed to develop and test a tumor-informed platform for ptDNA detection and validate its sensitivity and specificity against PLC. Methods: For this pilot study, peritoneal lavage fluid were collected at staging laparoscopy from 15 patients with gastroesophageal cancer. Cytology and peritoneal metastases (where clinically detectable) were confirmed by histopathology. A tumor-informed ptDNA testing was performed via whole-genome sequencing of tumor tissue and buffy coat to identify somatic variants for each patients, followed by tracking of up to 96 variants in each patient’s peritoneal fluid. Results: 5 out of 15 patients were either cytology positive or had macroscopic peritoneal disease and ptDNA was detectable in all 5 cases. Additionally, out of the 10 cytology-negative patients without macroscopic peritoneal disease, ptDNA positivity was detected in 6 patients prior to commencing neoadjuvant chemotherapy or surgery. Two of these 6 patients demonstrated radiological evidence of recurrence at 15- and 18-months follow-up respectively. Interestingly, one patient with macroscopic peritoneal disease tested negative for cytology. In this case, peritoneal lavage was carried out to the upper two abdominal quadrants only, and the pelvic deposit of disease was detected after the lavage had been completed. Despite a negative cytology result, ptDNA was detected using the same fluid sample, suggesting a higher sensitivity compared to PLC. Conclusions: This pilot study demonstrates that a tumor-informed ptDNA detection platform is feasible and potentially more sensitive than PLC in gastroesophageal cancer. To further validate the clinical utility of ptDNA we are proceeding to a multi-center prospective cohort study. Citation Format: Zexi Allan, Yuxuan Wang, Jeanne Tie, Niall Tebbutt, Nicholas Clemons, Nickolas Papadopoulos, Kenneth Kinzler, Bert Vogelstein, David SH Liu. Peritoneal tumor DNA as a prognostic biomarker in locally advanced gastroesophageal cancer: A pilot prospective cohort study [abstract]. In: Proceedings of the AACR Special Conference: Liquid Biopsy: From Discovery to Clinical Implementation; 2024 Nov 13-16; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(21_Suppl):Abstract nr A049.

Left-sided portal hypertension caused by a solid pseudopapillary neoplasm of pancreas tail: a pediatric case report

BackgroundSolid pseudopapillary neoplasm (SPN) is a low-grade malignant tumor that occurs in 60% of all pediatric pancreas tumors. Radical tumor resection is essential; however, spleen preservation is also crucial to prevent overwhelming post-splenectomy infection. In contrast, spleen preservation is not always possible, because left-sided portal hypertension (LSPH) can cause splenic vein stenosis or occlusion induced by pancreatic tumor. We herein report on a pediatric patient of LSPH due to SPN in the pancreatic tail.Case presentationA 12-year-old girl was admitted to our hospital with left upper quadrant abdominal pain. A solid mass was palpated in the left costal region. The patient showed slight anemia (Hb: 11.8 g/dL) and elevation of inflammatory reaction (CRP: 5.98 mg/dL) without positive tumor markers. A radiological examination revealed that a 9 cm-sized mass with hemorrhagic necrosis in the pancreatic tail. Splenic venous flow was not detected and collateral draining into the left gastric vein and left renal veins were developed with splenomegaly. LSPH was involved at the time of diagnosis. The tumor was diagnosed with SPN, hence tumor resection with spleen preservation was performed. Six months after surgery, the patient developed a left quadrant abdominal pain that worsened during exercise. There was no improvement of splenic venous flow and splenomegaly. LSPH remained with splenomegaly, which possibly triggered the patient’s abdominal pain. The patient underwent splenectomy 9 months after the tumor resection. After the splenectomy, the patient’s abdominal pain disappeared without any recurrence 8-year post-surgery.ConclusionsLSPH has not been a major focus in previous SPN pediatric patients, although most symptomatic LSPH patients required splenectomy. Careful post-operative observation for LSPH is important for pediatric SPN patients.

Sociodemographic predictors of imaging utilization in children with right lower quadrant pain.

Inequities in health care access lead to inequities in outcome. In recent years, health outcome disparities have been documented in children with acute appendicitis and sociodemographic predictors of imaging utilization have not been adequately assessed. The purpose of our study is to assess sociodemographic predictors for the diagnostic imaging of children with right lower quadrant (RLQ) pain. Our hypothesis is that disparities exist in imaging utilization. Our nationwide retrospective cohort study of the Pediatric Health Information System (PHIS) database queried emergency department encounters for children aged 0-18years presenting with RLQ pain (ICD code CM R10.31) between January 2018 and September 2023. Primary exposures included neighborhood-level sociodemographic metrics as measured by Child Opportunity Index, race/ethnicity, and insurance status. Outcomes included no diagnostic imaging, diagnostic imaging with radiography alone, ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Multivariable logistic regression analyses assessed modality usage with respect to the primary exposures after controlling for demographic (age, gender) and additional (hospital geographic region, time of imaging) covariates. To avoid the perpetuation of bias, reference categories were determined by the lowest numerical value for each covariate. In total, 100,161 patient encounters met inclusion criteria (mean patient age 11.2years ± 3.9; 59.3%, n = 59,416 females). Imaging utilized was US (78.0%; n = 78,115), CT (16.4%, n = 16,405), no imaging (13.9%, n = 13,894), radiography alone (4.4%, n = 4,429), and MRI (3.1%, n = 3,148). The most predictive factors for no imaging were moderate, low, and very low Child Opportunity Index (aOR 1.25, 1.17, and 1.18 [95% CI 1.10-1.33] compared to very high Child Opportunity Index); Black race/ethnicity (aOR 1.26 [95% CI 1.11-1.44] compared to White or Asian race/ethnicity); and public or other insurance (aOR 1.23 and 1.32 [95% CI 1.18-1.41] compared to commercial insurance). The most predictive factors for radiography alone were Black race/ethnicity (aOR 1.30 [95% CI 1.17-1.45] compared to Hispanic race/ethnicity) and public or other insurance (aOR 1.26 [95% CI 1.11-1.44] compared to commercial). The most predictive factors for US were very-high Child Opportunity Index (aOR 1.16 [95% CI 1.09-1.22] compared to very low Child Opportunity Index); Asian, NH-White, or Hispanic race/ethnicity (aOR 1.33, 1.31, 1.30 [95% CI 1.18-1.40] compared to Black race/ethnicity); and commercial insurance (aOR 1.20 [95% CI 1.16-1.25] compared to public insurance). The most predictive factor for CT was White race/ethnicity (aOR 1.26 [95% CI 1.11-1.43] compared with Asian race/ethnicity) and the most predictive factor for MRI was Hispanic race/ethnicity (aOR 1.49 [95% CI 1.17-1.61] compared with Black race/ethnicity). The greatest predictor of cross-sectional imaging was a hospital's region, with CT most likely in southern hospitals (aOR 4.09 [95% CI 2.17-7.70] compared with northeast hospitals). Patient Child Opportunity Index did not predict the likelihood of cross-sectional imaging with CT or MRI in tertiary pediatric centers. Sociodemographic disparities exist in the imaging of children presenting to tertiary pediatric hospitals with RLQ pain. Future studies are needed to analyze the causes of such disparities both on hospital and departmental levels.

What you need to know: Current management of acute appendicitis in adults

ABSTRACT Acute appendicitis is one of the most common acute surgical diseases in the world today. Acute appendicitis can present with a well-recognized clinical presentation with abdominal pain which localize in the right lower quadrant. This presentation is more typical in men than in women of child baring age. Several clinical and laboratory calculations can be used to increase the likelihood of making a correct diagnosis. Various imaging modalities can be used to make the diagnosis which include ultrasound, computer tomography, and magnetic resonance imaging. Each study has well known sensitivity/specificity of positive predictive value of making the diagnosis of appendicitis. The management of acute appendicitis is based on the presentation of the patient and dividing it into uncomplicated and complicated disease. Each requires management with antibiotics and followed with timely appendectomy. Recent studies have demonstrated nonoperative management of uncomplicated appendicitis without no fecalith that can be managed with antibiotics alone. Complicated acute appendicitis should undergo timely surgical intervention. Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management. There are certain patient populations that should be considered for surgical intervention. Pregnant patients as well as immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications. This review outlines the current principles of the diagnosis, imaging, and treatment of acute appendicitis based on the best available evidence of acute appendicitis in adults. LEVEL OF EVIDENCE Original Review Article, Level III.

How many is enough? Measuring the number of FAST exams needed by emergency medicine trainees to reach competence

BackgroundFor patients with blunt abdominal trauma, the Focused Assessment with Sonography in Trauma (FAST) exam is the initial imaging modality employed to diagnose and risk stratify. A positive FAST exam in this patient population denotes intraperitoneal hemorrhage. In a hemodynamically unstable patient, it necessitates rapid surgical intervention. Ultrasound is highly dependent on the operator’s ability to obtain quality images for interpretation. Failure to obtain adequate images prevents accurate interpretation and reduce its diagnostic accuracy. Previous studies evaluating whether the FAST exam can be improved solely by experience had conflicting results. None of those studies used an objective method to evaluate the FAST exam’s quality. Our study aimed to objectively determine the number of FAST exams required by an emergency medicine (EM) resident to reach sufficient quality for independent scanning.Methods59 first-year EM residents from a single site were included in this study. All FAST exams that were saved in the Qpath archival system by the 59 EM residents, whether the exam was performed for educational or clinical purposes, were reviewed, and scored using a Task-Specific Checklist (TSC) score. This score is an objective way to assess the proficiency and quality of the FAST scan. The TSC was based on whether the imaging of 24 specific anatomic landmarks, split into four anatomic regions, was completed successfully or not. The AEMUS (Advanced EM Ultrasonography) faculty provided feedback to trainees wither electronically via Qpath or at the bedside. According to the quality of ultrasound imaging and competence (QUICK Score), if the average TSC score for the first 10 exams was 18 or higher, the resident was considered an expert. However, if the resident failed to achieve that score, we skipped the first exam performed by the resident and the average score for the second through eleventh exams was then calculated. If the resident did not achieve the desired result, the first and second exams were skipped and the average score for the remaining 10 exams was determined. This sequence was repeated until the resident achieved an average score of 18 or higher on their TSC score.ResultsIn total, 663 FAST scans performed by EM residents were scored. The average number of FAST exams needed for independent scanning is 11.23 (95% CI, 10.6-11.85). 66.1% of enrolled residents achieved an average score of 18 or higher in their first 10 FAST exams, and 33.8% of residents required more than 10 scans. The average scores for the right upper quadrant (RUQ), left upper quadrant (LUQ), pelvic, and subxiphoid views were 5 (95% CI, 4.88–5.1), 4.7 (95% CI, 4.59–4.8), 5.1 (95% CI, 4.96–5.24), and 3.7 (95% CI 3.6–3.8) respectively.ConclusionThis study demonstrated that when constructive feedback on each FAST exam was given, the average first-year emergency medicine resident achieves competency in performing FAST exams independently after completing 10–12 (average of 11.23) FAST exams. Further research is required to validate the findings.

Use and Disuse of Catheterizable Channels as the Primary Method of Emptying the Neuropathic Bladder: A Single Institutional Cohort Study.

We aimed to assess long-term use of continent catheterizable urinary channels (CCCs) and explore potential risk factors of disuse. People undergoing appendicovesicostomy and Monti procedures at our institution were retrospectively reviewed (1991-2023). The main outcome was CCC disuse (not intermittently catheterizing channels as the primary method of bladder emptying). Cox regression was used. Five hundred sixty-one people (46% male, 57% shunted, 72% spina bifida) met inclusion criteria (244 appendicovesicostomy, 317 Monti; 69% right lower quadrant [RLQ]). Channels were created at a median age of 8 years (median follow-up: 11 years, 78% self-catheterized). Overall, 76 people disused their channels. The most common reasons for disuse were nonmechanical (64%). After disuse, 46% underwent incontinent diversion. After correcting for differential follow-up, 89% of people still used their channels at 10 years and 81% at 20 years. When analyzing all disused channels in patients reaching adulthood on multivariable analysis, channels catheterized by others had 3.78 times the risk of disuse compared with self-catheterized channels (P < .001); RLQ channels were 1.06 times more likely to be disused than umbilical channels (P = .02). For channels disused for nonmechanical reasons, catheterization by others, not attending transition clinic, and RLQ stoma were independently associated with disuse (P ≤ .04). No variables were associated with disuse for mechanical reasons (P ≥ .22). Most people with CCCs use them on long-term follow-up. One percent stopped using them annually. People who never self-catheterized, never attended transition clinic, or never had RLQ stomas were at higher risk of channel disuse, particularly because of nonmechanical reasons.

072. Subhepatic Appendicitis in A 23 Year Old Woman: A Rare Case Report

Background: Subhepatic appendicitis is a rare condition that occurs in only 0.01% of all acute appendicitis cases. The subhepatic position of the appendix is due to a developmental anomaly resulting from the failure of the caecum to descend during embryonic development. Its symptoms often resemble those of other diseases such as cholecystitis, pyelonephritis, and urolithiasis, which can lead to a delay in diagnosis and treatment. Case: A 23-year-old woman presented with four-day history of pain in the right upper quadrant of her abdomen, fever, anorexia, nausea, and vomiting. Abdominal examination revealed tenderness of all abdominal quadrants, which was more pronounced over the right upper and middle quadrant with positive rebound tenderness. Laboratory tests showed high levels of neutrophilic leukocytosis. Ultrasound imaging revealed an inflamed vermiform appendix in the subhepatic region. A diagnosis of an abnormally located appendix was made, and the patient underwent laparotomy. During exploration, an inflamed appendix was found covered by omentum in the right upper quadrant, and appendectomy was carried out smoothly. The patient was in good clinical condition without any complications. Conclusion: Subhepatic appendicitis presents a significant challenge to clinicians due to its unusual location. Failure to diagnose and manage it promptly can lead to complications such as abscesses, peritonitis, sepsis, and increased morbidity. Midline laparotomy is recommended due to the subhepatic location of the appendix and the possibility of retrocecal, dense adhesion or fibrosis, and perforation, which would make a laparoscopic approach unsafe.

Perforated Meckel’s Diverticulum: A Case Report

Meckel’s diverticulum is a true diverticulum that consists of all layers of bowel normally found in a normal small bowel wall. The three most common presentations in children are intestinal bleeding (30–56%), intestinal obstruction (14–42%), and diverticular inflammation (6–14%). Complications result in more severe symptoms, such as acute abdomen and signs of peritonitis. These presentations are not specific to Meckel’s diverticulum and can be found in many other conditions, making the diagnosis difficult. A five-year-old child came to the emergency department with complaint of acute abdominal pain, especially in the right lower quadrant. The pain was accompanied by vomiting. On physical examination, patient was febrile and signs of peritonitis were found. Abdominal plain film revealed the probability of focal inflammation in the right lower region of the abdomen, with partial intestinal obstruction. Ultrasonography showed a presence of a mass in right iliac region with the size of 24x20x23 mm, with normal appendix. During exploratory laparotomy, a necrotic and perforated Meckel’s diverticulum was found, with associated purulent matter. Diverticulectomy with segmental resection of ileum followed by end-to-end anastomosis were done. Diagnosis of Meckel’s diverticulum requires a high index of suspicion, especially in the pediatric population. It is important for clinicians to be aware of unusual presentations of Meckel’s diverticulum.

The two-stage detection-after-segmentation model improves the accuracy of identifying subdiaphragmatic lesions

Chest X-rays (CXRs) are primarily used to detect lung lesions. While the abdominal portion of CXRs can sometimes reveal critical conditions, research in this area is limited. To address this, we introduce a two-stage architecture that separates the abdominal region from the CXR and detects abdominal lesions using a specialized dataset. We compared the performance of our method on whole CXRs versus isolated abdominal regions. First, we created masks for the right upper quadrant (RUQ), left upper quadrant (LUQ), and upper abdomen (ABD) regions and trained corresponding segmentation models for each area. For detecting abdominal lesions, we curated a dataset of 5,996 images, categorized into 19 classes based on anatomical locations, air patterns, and levels of stomach or bowel dilation. The detection process was initially conducted on the original images, followed by the three regional areas, RUQ, LUQ, and ABD, extracted by the segmentation models. The results showed that the detection model trained on the entire ABD region achieved the highest accuracy, followed closely by the RUQ and LUQ models. In contrast, the CXR model had the lowest accuracy. This study highlights that the two-stage architecture effectively manages distinct segmentation and detection tasks in CXRs, offering a promising avenue for more accurate diagnoses. It also suggests that an optimal ratio between the sizes of the target lesions and the input images may exist.

The Great Mimicker: Goblet Cell Adenocarcinoma of the Appendix Mimicking Mammary Carcinoma in a Patient with a History of Metastatic Breast Cancer

Abstract Introduction/Objective Goblet cell adenocarcinoma of the appendix is a rare and aggressive malignancy with high- grade histological patterns that pose diagnostic challenges due to their resemblance to other tumors. Previous reports have indicated that high-grade goblet cell adenocarcinoma may exhibit similarities to well-differentiated neuroendocrine tumors, and metastatic high-grade goblet cell adenocarcinoma can manifest diverse histologic growth patterns within a single section. Methods/Case Report We present a case of an 82-year-old female with a known history of breast cancer with sacral metastasis, presenting with a left upper quadrant “pinching” sensation. Histopathological examination following colectomy showed features of metastatic mammary carcinoma with mixed lobular (pleomorphic and partial signet ring cell type) and ductal features (Figure 1); Notably, different histologic patterns were observed in two tumor deposits, highlighting the complexity of the diagnosis (Figure 2). However, further investigation of the tip of the appendix revealed goblet-like mucinous cells arranged in a tubular growth pattern (Figure 3). Immunohistochemical stains were performed with adequate controls, revealing positive staining for CK20, SATB2, and CDX2, while showing negativity for BRST2, SATB2, GATA3, CK7, PR, ER, and HER2 (Figure 4). These findings corroborate the diagnosis of goblet cell adenocarcinoma. Results (if a Case Study enter NA) NA Conclusion In our case, we observed morphological features of goblet cell adenocarcinoma that overlapped with those of established mammary carcinomas. This scenario underscores the diagnostic challenges posed by rare tumors and emphasizes the significance of identifying the low-grade component of goblet cell adenocarcinoma, particularly in patients with a history of metastatic breast cancer.

EVERY KERATIN-POSITIVE MALIGNANT TUMOR IN THE ADRENAL GLAND IS NOT METASTATIC CARCINOMA- A CASE REPORT

Abstract Introduction/Objective Angiosarcoma is a rare subtype of sarcoma arising from the vascular endothelial cells. Primary adrenal angiosarcoma (PAA) is an exceedingly rare entity, with only 53 cases documented in the literature so far. Methods/Case Report A 78-year-old female presented with left upper quadrant abdominal pain and early satiety. A computed tomography scan of the abdomen revealed a 15 x 13 x 16 cm, heterogeneous enhancing mass with interspersed calcifications, possibly originating from the left adrenal gland. The mass was found to be displacing the spleen and the left kidney. An ultrasound-guided biopsy of the mass was inconclusive, and the patient subsequently underwent resection of the left retroperitoneal mass, left adrenalectomy, splenectomy, and left partial nephrectomy. Gross examination revealed a slightly ruptured, red-brown mass (19.5 x 12.7 x 12.6 cm, 1784g), which was serially sectioned to reveal diffusely hemorrhagic and necrotic cut surfaces. On microscopic examination, the tumor was almost entirely hemorrhagic and necrotic, with a few viable areas that were composed of solid sheets of markedly pleomorphic epithelioid cells with a high nuclear-cytoplasmic ratio, prominent nucleoli, and increased mitotic figures. There were also a few ectatic vascular spaces lined by these markedly pleomorphic epithelioid cells. Immunohistochemical stains of the tumor cells showed positive results for cytokeratins, CD31, ERG, and friend leukemic integration 1 (FLI-1), while Inhibin and SF-1 were negative. A diagnosis of epithelioid angiosarcoma was rendered. Results (if a Case Study enter NA) NA Conclusion PAA can be difficult to diagnose since it is rare, and thus it is not typically considered in the initial differential diagnosis. Most PAA have an epithelioid morphology, and they frequently test positive for cytokeratins. Biopsy diagnosis can also be challenging, as the mass may exhibit extensive necrosis and hemorrhage. Considering its rarity, large adrenal masses with heterogeneous features on imaging PAA should be considered as a differential diagnosis.

Key Factors for Predicting Appendicitis from Contrast-Enhanced Computed Tomography Images Obtained Through Multiplanar Reconstruction

Background: The diameter of the appendix is a key parameter in diagnosing appendicitis. The diagnostic threshold for this parameter is 6 mm, originally established through graded compression sonography of the right lower quadrant (RLQ) of the abdomen. However, without corroborative findings from computed tomography (CT), this threshold may not be a reliable indicator of appendicitis. To ensure accurate diagnosis, clinicians should perform a comprehensive, multiparameter imaging assessment of the appendix, rather than relying solely on appendix diameter. Objectives: This study aimed to identify key factors for predicting appendicitis using contrast-enhanced coronal and sagittal CT images obtained through multiplanar reconstruction. Patients and Methods: This single-center, retrospective, cross-sectional study included patients who presented to our emergency department (ED) with RLQ abdominal pain and subsequently underwent contrast-enhanced CT between July 2019 and September 2020. The primary study outcome was pathologically confirmed appendicitis. Two experienced radiologists assessed parameters such as appendix diameter, wall thickness, abnormal appendix enhancement, abnormal appendix content, appendix erection, and periappendiceal fat stranding. Multivariate logistic regression was performed to identify significant predictive factors for appendicitis. Results: The study included 173 patients (median age: 37 years; women: 86). They were divided into appendicitis (n = 102) and alternative diagnosis (n = 71) groups. Significant differences were observed between the groups in terms of appendix diameter, wall thickness, wall enhancement, luminal content, appendix erection, and periappendiceal fat stranding (P &lt; 0.001). The diagnostic sensitivity and specificity values for an appendix diameter threshold of 7.7 mm were 91% and 82%, respectively. An appendix diameter of &gt; 7.7 mm (OR: 15.3; P &lt; 0.001), abnormal appendix enhancement (OR: 12.5; P &lt; 0.001), and appendix erection (OR: 6.1; P = 0.004) emerged as significant independent predictors of appendicitis. Conclusion: An appendix diameter of 7.7 mm appears to be the optimal threshold for diagnosing appendicitis. Additionally, the detection of abnormal appendix enhancement and appendix erection on contrast-enhanced CT images holds considerable diagnostic value.

A Cross-Sectional Study On Determination Of Age From Third Molar Tooth Eruption In The Population Of Telangana.

Age has got significant role in Forensic medicine. It helps in identification and correlates various civil and criminal related issues. A cross sectional study on age determination from eruption of third molar tooth was conducted at Malla Reddy Institute of Medical sciences Hyderabad Telangana for a period of one year in the age group between 18 years to 25 years. A total of 160 medical students were participated in which 80 males and 80 females were participated in the study. Each individual was examined for physical dental examination in each quadrant of the jaw, mere appearance of crown of the third molar tooth was considered as erupted. A space between the second molar tooth and the ramus of the mandible without any evidence of the crown of the 3rd molar tooth was considered as not erupted. Statistical results reveal 54.2% of the study population third molar teeth eruption was observed first in the lower left quadrant. 96.2% in male and 98.4% in female individuals third molar was erupted at 22 years of age and at 23 years third molar was completely erupted in all the quadrants of the jaw in both male and female population.

8557 Osteitis Fibrosa Cystica as the Initial Manifestation of Severe Primary Hyperparathyroidism: A Case Report

Abstract Disclosure: L.A. Robles Gomez: None. G. Gill: None. A. Vincent, DO: None. A. Mahmoud, MD: None. Introduction: Osteitis fibrosa cystica (OFC) is a pathognomonic yet uncommon finding of hyperparathyroidism seen in less than 2% of patients with primary hyperparathyroidism in Western countries. We present a case of infrequent finding of late-stage severe hyperthyroidism with asymptomatic hypercalcemia and incidental findings of osteolytic bone lesions. Clinical Case: A 28-year-old female with a history of PCOS, fatigue, and chronic abdominal pain presents to the clinic after recent work-up during an ED visit demonstrated incidental findings of osteolytic bone lesions in the setting of mild hypercalcemia. Physical examination was relatively unremarkable except for mild tenderness to palpation on the right lower quadrant. Laboratory significant calcium 10.7 mg/dl (8.6-10.2 mg/dL), albumin 3.6 g/dL, Creatinine 0.56 mg/dL, GFR 127 mL/min, Alkaline phosphatase 187 IU/L (37-127 IU/L), AST 24 IU/L, ALT 45 IU/L, Intact PTH and calcium: PTH 413 pg/mL (15-65 pg/mL), Calcium 11.5 (8.7-10.4 mg/dL), Bone Specific Alkaline Phosphatase: 54.5 mcg/L (4.7-17.8 mcg/L), Phosphorus 2.1 mg/dL (2.4-4.8 mg/dL), Magnesium 1.7 mg/dL (1.5-2.5 mg/dL), Vitamin D 25 10 mg/mL (20-100 ng/mL), TSH 2.12 uIU/mL (0.46-5.05 uIU/mL). CT abdomen pelvis w/o contrast with multiple predominantly lytic expansile bone lesions, mainly in the pelvis, with the most extensive 6.2 cm lesion in the superior, posterior right ilium, the anterior acetabulum, and the posterior right ischium. A prior CT done in 2018 showed a similar distribution of lytic lesions. The patient denied any previous personal or family history of hypercalcemia or parathyroid abnormalities despite a review of prior outside records revealed abnormal labs dating back to 2018 with intact PTH 406 pg/mL, calcium 10.3 mg/dL, Ionized calcium 10.7 mg/dl (3.30-6.0 mg/dL), albumin 3.3g/dL, alkaline phosphatase 288 IU/L. The patient denied prior symptomatology of hypercalcemia, including renal stones, or prior treatment for hypercalcemia. Further work-up was ordered, and the patient was referred to endocrine surgery for management. Conclusion: Osteitis fibrosa cystica (OFC) has become a rare manifestation of primary hyperparathyroidism (PHPT) due to early diagnosis of hypercalcemia by routine lab monitoring. Skeletal findings typically seen on PHPT can vary from bone reabsorption-acroosteolysis, subchondral bone resorption, brown tumors, salt-and-pepper skull, and osteopenia. Subchondral reabsorption around specific joints commonly affects pubic symphysis and sacroiliac joints, as seen in our patient. The mechanism is due to PTH-mediated osteoclastic absorption of bone and surrounding cartilage. Due to the rare presentation of PHPT with associated osteitis fibrosa cystica, diagnosis requires a high degree of clinical suspicion, as delayed diagnosis can lead to avoided manifestation, as described by our report. Presentation: 6/3/2024

6694 A Case of an Extraneous Organ: A Uterus Found in a Genotypic and Phenotypic Male

Abstract Disclosure: R.A. Zielinski: None. S. Shteyman: None. A.G. Samat: None. Background: Persistent Mullerian Duct Syndrome (PMDS) is a rare entity that occurs when a phenotypic male is found to have female reproductive organs. In our case we describe an XY male who was found to have an abdominal mass consistent with a uterus on pathology. Clinical Case: Our patient is a 58-year-old male with hypertension, obesity, and obstructive sleep apnea who presented to the ED with 3 weeks of left upper quadrant pain. Abdominal CT showed two homogeneous enhancing oval lesions in the pelvis superior to the urinary bladder; 8.3 x 4.6 cm on the right and 3.6 x 3 cm on the left. Exploratory laparotomy was performed, and intraoperatively the mass was firm with a left satellite lesion and two fibrous bands that appeared similar in structure to round ligaments. Microscopically the tissue contained mullerian-type epithelium and smooth muscle with cystic degeneration. It was CK7 positive, estrogen receptor variable positive, and CK20 negative. Genetic testing confirmed the patient’s karyotype to be XY without genetic mosaicism. Our patient had two children spontaneously, regular spontaneous erections, and occasional hot flashes. Physical exam revealed an obese male (BMI 51) with bilateral gynecomastia and normal testicular size. He had no history of intra-abdominal or undescended testes requiring surgery. Labs showed increased total estrogen (283.7 pg/mL, n 60-190 pg/mL) and estradiol (39 pg/mL, n &amp;lt;= 29 pg/mL), decreased total testosterone (86 ng/dL, n 250-1,100 ng/dL), and normal free testosterone when corrected for SHBG (140 ng/dL, n 110-574 ng/dL). Testicular ultrasound was unrevealing. 3 years postoperatively his estradiol level normalized (34 pg/mL) and his total testosterone improved from 86 ng/dL to 223 ng/dL after losing 40 pounds on semaglutide. Discussion and Conclusion: Although the exact incidence of PMDS is unknown, it is a rare phenomenon. Only 200 cases between 1964 and 2000 and 34 cases between 2013 and 2017 have been reported. Mullerian ducts are embryologic structures present in both XY and XX fetuses until week 8 of life, when XY fetuses produce anti-mullerian hormone (AMH). In PMDS, the XY fetus either fails to produce AMH, or there is a defect in the AMH receptors, leading to the persistence of mullerian ducts. These ducts can then differentiate into a uterus, fallopian tubes, and/or the upper vagina. Our patient is a genotypical and phenotypical male with a uterus-like organ. The mild elevation in his estrogen level is likely secondary to his obesity. The estrogen could have increased the size of the uterus, causing the patient’s initial symptoms of abdominal pain which prompted his presentation to the hospital.

Comparison of 6 handheld ultrasound devices by point-of-care ultrasound experts: a cross-sectional study

BackgroundPoint-of-care ultrasound (POCUS) has emerged as an essential bedside tool for clinicians, but lack of access to ultrasound equipment has been a top barrier to POCUS use. Recently, several handheld ultrasound devices (“handhelds”) have become available, and clinicians are seeking data to guide purchasing decisions. Few comparative studies of different handhelds have been done. We conducted a cross-sectional study comparing 6 handhelds readily available in the United States (Butterfly iQ + ™ by Butterfly Network Inc.; Clarius™ by Clarius Mobile Health; Kosmos™ by EchoNous; TE Air™ by Mindray; Vscan Air™ SL and CL by General Electric; and Lumify™ by Philips Healthcare). A multi-specialty group of physician POCUS experts (n = 35) acquired three standard ultrasound views (abdominal right upper quadrant, cardiac apical 4-chamber, and superficial neck and lung views) in random order on the same standardized patients and rated the image quality. Afterward, a final survey of the overall ease of use, image quality, and satisfaction of each handheld was completed.ResultsThirty-five POCUS experts specializing in internal medicine/hospital medicine, critical care, emergency medicine, and nephrology acquired and rated right upper quadrant, apical 4-chamber, and superficial neck and lung views with 6 different handhelds. For image quality, the highest-rated handhelds were Vscan Air™ for the right upper quadrant view, Mindray TE Air™ for the cardiac apical 4-chamber view, and Lumify™ for superficial views of the neck and lung. Overall satisfaction with image quality was highest with Vscan Air™, Lumify™, and Mindray, while overall satisfaction with ease of use was highest with Vscan Air™. The 5 most desirable characteristics of handhelds were image quality, ease of use, portability, probe size, and battery life. Ultimately, all 6 handhelds had notable advantages and disadvantages, with no single device having all desired qualities or features.ConclusionsThe overall satisfaction with image quality was rated highest with Vscan Air™, Lumify™, and Mindray TE Air™when acquiring right upper quadrant, apical 4-chamber, and superficial neck and lung views. No single handheld was perceived to be superior in image quality for all views. Vscan Air™ was rated highest for overall ease of use and was the most preferred handheld for purchase by POCUS experts.

S2913 Chronic Left Lower Quadrant Pain and Iron Deficiency Anemia in a Young Lady Mimicking a Colonic Endometrioma: Consider Cavernous Hemangioma of the Sigmoid

S2913 Chronic Left Lower Quadrant Pain and Iron Deficiency Anemia in a Young Lady Mimicking a Colonic Endometrioma: Consider Cavernous Hemangioma of the Sigmoid