Mid Abdomen Research Articles

S3689 Small Bowel Obstruction in COVID-19 Patient Without Risk Factors

Introduction: The documented gastrointestinal associations of COVID-19 infection include enteritis, colitis, ileus, and mesenteric thrombosis from associated coagulopathy. A direct link to small bowel obstruction (SBO) has yet to be proposed. Aside from isolated cases of bacterial enteritis, infection is not a widely accepted cause of SBO. SBO is mostly caused by adhesions formed after intra-abdominal surgery. Other causes include congenital adhesions, neoplasms, hernias, and stenosis from inflammatory bowel disease (IBD) or bowel ischemia. We report a unique case of acute SBO in a patient with COVID-19 symptoms but no known risk factors of SBO. Case Description/Methods: A 67-year-old man with history of HTN and TURP for BPH presented with intermittent fever and dry cough for 1 week. He had no history of abdominal surgery, hernia, malignancy, IBD, or bowel ischemia. He was febrile to 102.6F and O2 saturation was 100% on room air without respiratory distress. SARS-CoV-2 PCR assay was positive. After two days of remdesivir, he was hypoxic requiring nasal cannula and had abdominal pain with loose stool. On exam, abdomen was distended with guarding. CT abdomen showed 2 transition points, multiple dilated bowel loops, and fluid and stool in distal bowel consistent with partial SBO. Nasogastric tube drained gastric contents with bile. He was intubated for ex-lap which showed no transition points or congenital adhesions. Proximal two-thirds of bowel were dilated, thickened, and hyperemic but the distal third was normal caliber. Creeping fat and friable mesentery with ecchymosis were noted throughout. Abdomen was left open with plan for closure the following day. Closure was delayed by 4 days due to worsening hypoxia and new pressor requirements. Oxygen and pressor requirements improved after starting steroid and antibiotic treatment. Abdomen was then closed as bowel remained viable. He was extubated, weaned to room air, and able to tolerate food within 1 week followed by discharge to rehab. Discussion: In our patient who developed partial SBO in the setting of worsening COVID-19 respiratory symptoms with no history of intra-abdominal surgery or other risk factors of SBO, COVID-19 should be considered as a possible etiology. Ex-lap findings were non-specific and could indicate inflammatory or ischemic evidence of COVID-19 gut involvement. Further research is required to better understand this patient’s diagnosis and a possible relationship between COVID-19 enteritis and acute development of SBO.Figure 1:: CT Abdomen Showing Two Transition Points Image A: Transition point in left mid abdomen. Image B: Transition point in right mid abdomen.

S2884 Pelvic Inflammatory Disease as an Unusual Cause of Ascites

Introduction: Pelvic inflammatory disease (PID) is an infection of the upper genital tract, including the uterus, fallopian tubes, and/or ovaries. Neisseria gonorrhea, Chlamydia trachomatis, and Mycoplasma genitalium are the most frequently isolated pathogens. Case Description/Methods: A 25-year-old female presented with an 8-day history of lower abdominal pain associated with fevers, chills, vomiting, and non-bloody diarrhea. Patient denied recent travel, changes in her diet, family history of Inflammatory Bowel Disease. Her abdomen was diffusely tender. Routine laboratory testing was unremarkable. CT scan of the abdomen and pelvis (Figure 1) showed focal small bowel mural thickening, concerning for gastroenteritis. COVID PCR, HIV antigen/antibody, blood cultures, Clostridium difficile toxin and stool pathogen PCR panel were all negative. Patient was presumed to have viral gastroenteritis and was discharged home. She was readmitted two days later for worsening nausea and vomiting. Laboratory testing was significant for WBC 12.7 x 109/L, potassium of 2.8 mEq, INR 1.7, CRP 19.24 mg/dL. A repeat CT abdomen and pelvis (Figure 2) showed a re-demonstration of marked wall thickening of the small bowel most consistent with enteritis, and the development of large loculated ascites in the mid abdomen and pelvis with peritoneal thickening and enhancement. Diagnostic paracentesis showed PMNs 990, RBCs 4000, SAAG < 1.1, total protein 3.7 g/dl, glucose 29 mg/dl, and LDH 1609 U/L. Peritoneal cultures grew Neisseria gonorrhea. Patient was discharged home on a two-week course of IV ceftriaxone, metronidazole and doxycycline with improvement in clinical symptoms. Repeat diagnostic imaging showed interval improvement and resolution of ascites. Discussion: Acute symptomatic PID presents with lower abdominal pain associated with fevers, chills, nausea, vomiting, vaginal discharge and/or intermenstrual bleeding. PID may present with RUQ pain in the setting of liver capsular inflammation, also known as perihepatitis i.e. Fitz-Hugh Curtis Syndrome. Perihepatitis occurs in about 10% of woman with acute PID. However, the development of ascites as a presenting complication of PID is very rare. In this case, the ascites fluid studies were not consistent with portal hypertension with a SAAG < 1.1. In addition, PMNs > 250 cells suggested bacterial peritonitis. Furthermore, per the Runyon’s criteria, this pattern resembled secondary bacterial peritonitis with a total protein >1 g/dL, glucose < 50 mg/dL, and LDH > upper limit of normal serum.Figure 1.: CT abdomen and pelvis on presentation showing small bowel mural thickening and enhancement.Figure 2.: CT abdomen and pelvis on representation showing large volume ascites with continued small bowel mural thickening and enhancement.

Components separation technique of the abdominal wall: Which muscle release produces the greatest reduction in tension on the mideline?

The components separation technique (CS) is used for the reconstruction of complex abdominal wall defects. Release and undermining of the rectus abdominis muscle (RAM) and external oblique muscle (EOM) decrease tension on the abdominal midline, reducing recurrence of ventral hernia, but causes major changes in the physiology of abdominal wall. The purpose of the study was to determine which muscle release and undermining produces the lowest tension on the midline. Twenty fresh cadavers were dissected and the anterior and posterior layers of the rectus sheath were isolated in the midline. The forces necessary to advance the layers of the rectus sheath to the mid abdomen were measured bilaterally at two points located 3 cm above and 2 cm below the umbilicus, and at 3 different stages: before any muscle release; after release and undermining of the right RAM and left EOM; and after release and undermining of the left RAM and right EOM. Comparisons of tensile forces were conducted separately for the different muscles involved, layers of the rectus sheath, measurement points, and stages of separation. Tension on the abdominal midline after the release and undermining of both the RAM and EOM was reduced by 56% (p <0.05), 42% after the release and undermining of the EOM alone (p <0.05), and 35% after release and undermining of the RAM alone (p <0.05). Release and undermining of the EOM by CS led to lower tension on the abdominal midline compared to that associated with the release of the RAM alone.

Transaminitis Evaluation Leads to the Incidental Diagnosis of Familial Paraganglioma Due to SDHB Mutation

Background: Paragangliomas are rare neuroendocrine tumors. Patients with succinate dehydrogenase subunit B (SDHB) gene mutations are predisposed to developing paraganglioma/pheochromocytoma. We are presenting the case of an incidental finding of a paraganglioma during an evaluation for transaminitis. Clinical Case: A 23-year-old male with a medical history of right hydrocele repair as a teenager was evaluated with an ultrasound of the abdomen for elevated liver enzymes and right upper quadrant discomfort. The ultrasound revealed a large lobular solid vascular 13.8 x 8.1 x 11.3 cm mass in the mid abdomen. He underwent a CT of the chest, abdomen and pelvis which demonstrated a large retroperitoneal mass measuring 16 x 10 x 13.7 cm within the right mid abdomen. The mass was described as a large centrally necrotic peripherally enhancing right retroperitoneal mass displacing the IVC anteriorly. The patient subsequently underwent an image-guided biopsy of the mass and the pathology revealed it was a paraganglioma. The patient denied any history of hypertension, orthostasis, headaches or palpitations. Biochemical workup for plasma catecholamines, plasma metanephrines, 24-hour urine catecholamines and metanephrines and cortisol were unremarkable. His transaminitis also resolved. He underwent a retroperitoneal paraganglioma excision and the final pathology was consistent with paraganglioma and negative for capsular invasion. He was referred to a genetic counsellor for testing since paragangliomas can be inherited. He also mentioned a family history of breast cancer in his mother and HTN and prostate cancer in his father. His test revealed that he had a c.289A>T mutation in his SDHB gene. He was encouraged to share the information with his family to help them understand the implications of his genetic test result. He underwent a surveillance PET scan which showed multiple osseous lesions in his temporal calvarium, sphenoid, spine and sacrum suggestive of metastasis. Repeat imaging with a DOTATATE PET scan showed stable disease. His transaminitis was transient, and we did not find a correlation to his paraganglioma. His imaging tests showed no liver metastasis. A CT of the head showed no evidence of intracranial metastasis. The current plan is to continue surveillance. His older brother underwent a genetic testing. He tested positive for the same SDHB mutation and underwent biochemical and imaging tests which were unremarkable. He too will continue surveillance. Conclusions: Patients with a succinate dehydrogenase subunit B (SDHB) gene mutations are predisposed to developing paraganglioma/pheochromocytoma. The tumors produce catecholamines, but can be biochemically silent as in our patient. They are inherited in an autosomal dominant manner. Our case highlights the importance for genetic counseling which increases the chances of early screening and surveillance in affected family members for optimal multidisciplinary management of patients.

Mesenteric Ischemia in a Young Man With the First Presentation of Diabetic Ketoacidosis

Background: Diabetic Ketoacidosis is known as an inflammatory state. Review of literature shows a number of cases of mesenteric ischemia described in the adolescent and adult population with long term IDDM. There have also been publications and reports of pediatric patients developing strokes.(1) However there are no reports of adults presenting with the first episode of DKA associated with acute mesenteric ischemia. The hypercoagulable state of DKA has been attributed to decreased activity of protein C and S. VWF activity and factor have also been shown to be increased prior to initiation of treatment and activity was shown to be continuously increased even at 120 hours after treatment. The prothrombotic state and activation of the vascular endothelium is thought be secondary to increased vWF and the decreased levels of protein C activity and of free protein S.(2)Clinical case: 37 year old man with no known past medical history presented with a few day history of abdominal pain, nausea and vomiting. He was found to be significantly hyperglycemic at 635mg/dL, acidotic with bicarb level of 6mEq/L and ABG Ph of 6.9. He was also found to have elevated B hydroxybutyrate >5.5mmol/L and ketones in urine. CT scan of the abdomen was nonspecific and he was started on an insulin drip and the treatment protocol for DKA. His lactic acidosis resolved from 3.9mmol/L to 0.8mmol/L. He clinically improved and started tolerating liquids and oral diet within a few hours. 36 hours after presentation, the patient reported recurrence of abdominal pain and nausea. Lab work up showed recurrence of lactic acidosis. His pain intensified and a repeat ct scan of the abdomen showed multiple dilated fluid filled loops with a transition point in the mid abdomen. Mesenteric vein gas was also noted which was concerning for SMA thrombosis and gut ischemia. Emergent surgical consultation was requested and the patient underwent exploratory laparoscopy and laparotomy which showed extensive small bowel ischemia with 135cm of unaffected small bowel. Patient underwent bowel resection and SMA arteriogram. He then required repeat surgery for inspection of bowels and closure of abdomen. Patient was liberated from the ventilator, and as his bowel function recovered, he was restarted on a clear liquid diet and advanced to a regular diabetic diet prior to discharge.Conclusion: This is a rare case of mesenteric ischemic in the setting of the first episode of DKA in an adult man. Both DKA and mesenteric ischemia are potentially fatal. Prognosis depends on detection and early treatment of both conditions. Persistent or recurrent abdominal pain, nausea and vomiting should raise concern for thrombotic and inflammatory complications of DKA.1. Ho J, Pacaud D, Hill MD, Ross C, Harniwka L, Mah JK. Diabetic ketoacidosis and pediatric stroke. CMAJ 2005;172(3):327–8. [PMC free article] [PubMed]2.Carl GF, Hoffman WH, Passmore GG, Truemper EJ, Lightsey AL, Cornwell PE, Jonah MH. Diabetic ketoacidosis promotes a prothrombotic state. Endocr Res. 2003 Feb;29(1):73–82. doi: 10.1081/erc-120018678. PMID: 12665320.

POS-695 INTESTINAL OBSTRUCTION COMPLICATING CAMPYLOBATER COLI ENTERITIS IN RENAL TRASNPLANTATION PATIENT

A 30 year old male, with cadaveric renal transplantation 2 years ago , his primary disease was anti-GBM disease diagnosed one year prior to transplantation and treated with 14 sessions of plasma exchange, steroids and cyclophosphamide shortly after that he was initiated on hemodialysis followed by renal transplantation. Two months post renal transplantation his course was complicated by biopsy proven mixed rejection (T-Cell mediated rejection type IA) and active Antibody medicated rejection , however ,C4d negative. The patient received pulsed steroids, 3 sessions Plasma-exchange and IVIG 2g/kg. He completed 2 doses of Rituximab and his serum creatinine was stable at 200-220 micromole/L. The patient was admitted after 3 weeks with persistent vomiting and abdominal pain and abdominal distention, his serum creatinine 304 micromole/L, abdominal x-ray showed multiple air fluid levels with dilatation of small bowel loops. CT scan with oral contrast showed multiple dilated small bowel loops down to the terminal ileum with caliber of 3.5 mm with multiple air-fluid levels and fecal loading in distal ileum loop with collapsed colon. The contrast media reached into the small bowel in left mid abdomen at mid jejunal loop. Stool culture grew campylobacter coli, BK PCR was positive of 371,000 copies. Other infectious causes of diarrhea were excluded. The patient completed 7 days of ciprofloxacin and treated with intravenous immunoglobulins (IVIG) . His mycophenolic acid was stopped, and he was maintained on dual immunosuppression therapy in form of tacrolimus and steroids. The patient was booked for upper endoscopy and colonoscopy in outpatient setting. View Large Image Figure ViewerDownload Hi-res image Download (PPT) Diarrhea is a common symptom in renal transplant patient population. The main causes of diarrhea after transplantation include infections, immunosuppressive drugs, antibiotics, and other drugs. Viral causes of diarrhea are the most frequently reported and usually last up to 3 days. Patients have tendency to develop Clostridium difficile after antibiotics. Other enteric bacteria responsible for diarrhea are Shigella, Salmonella typhi, Salmonella typhimurium and Campylobacter. CMV can cause enterocolitis, with or without fever, gastrointestinal bleeding, perforation, and toxic megacolon are possible complications. Incidence of diarrhea with mycophenolate mofetil dose of 2 g/day was higher than in other immunosuppressants like azathioprine. Campylobacter infection has prominent features like terminal ileitis, cecitis and mesenteric adenitis. Proton pump inhibitors are main risk factor for campylobacter enteritis as it lowers the gastric juice acidity allowing for pathogen survival. Campylobacter was detected in stool culture of a 31-year-old male patient diagnosed with immunoproliferative small intestinal disease (IPSID) and it was positive in tissue biopsy samples. Antibiotics treatment is enough to eradicate campylobacter and reduce the risk of IPSID. Diarrhea is a common symptom post renal transplantation, Campylobacter coli can be one of the main causes of ileocecal enteritis and may cause small bowel obstruction, treatment is usually conservative with antibiotics.

Robotic hepaticojejunostomy for biliary stricture after liver transplantation: technical description and case series

Presenter: Jason Hawksworth MD | MedStar Georgetown University Hospital Background: Biliary strictures after liver transplantation are common and when refractive to endoscopic and percutaneous intervention require surgical biliary revision. Traditional open biliary revision may result in substantial wound morbidity and prolonged hospitalization in this high-risk population. Robotic technology facilitates minimally invasive biliary reconstruction and has not previously been described following liver transplantation. Methods: A brief description of the robotic approach is as follows: Peritoneal access is obtained at the umbilicus and a 12mm assist port is placed. Robotic ports are placed across the mid abdomen parallel to the umbilical port including 3x 8mm ports and 1x 12mm port. Lysis of adhesions is performed until the liver hilum is isolated. The bile duct is encircled and the stricture resected until healthy appearing donor bile duct is visualized. The hilar inflow structures are carefully preserved during this dissection. The inframesocolic compartment is exposed and the first jejunal loop divided with the robotic stapler. The roux limb is routed retrocolic and an isoperistaltic end-to-side jejunojejunostomy created with the robotic stapler. The common enterotomy is closed with running suture. Attention is returned to the liver hilum where an end-to-side hepaticojejunostomy is created with interrupted monofilament suture. Ultrasound is used during the case to aid in identification of the hilar structures and at the end of the case to confirm patency of the hepatic artery. The robotic cases were retrospectively compared to historical open cases over a time period from May 2013 to October 2020, including demographics, perioperative complications and outcomes. All patients had at least 3 months follow up. Results: During the study period there were 3 robotic and 4 open surgical biliary revisions. All cases were hepaticojejunostomies for choledochocholedochostomy related anastomotic strictures. In one robotic case involving a donation after cardiac death (DCD) graft, the bile duct was also noted to be sclerotic up to the liver hilum and the anastomosis was fashioned to the right and left hepatic ducts. In all cases the biliary strictures presented >90 days after transplant and were refractive to multiple endoscopic and percutaneous interventions. Median (range) case time was longer the in the robotic (373 minutes (286-373)) compared to open (280 minutes (163-321)) group. Blood loss was minimal ( < 50mL) in all robotic and open cases. The median length of stay was lower in the robotic (4 days (1-4)) compared to open (7 days (4-10)) group. Morbidity included 2 wound infections in the open group (grade 2), 1 gastrointestinal bleed requiring a blood transfusion in the robotic group (grade II), 1 infected hematoma in the robotic group (grade IIIa) and 1 bile leak on the open group (grade IIIa). Nadir bilirubin was similar between the robotic (0.2 (0.2-0.3)) and the open (0.3 (0.2-0.4)) group. Nadir alkaline phosphatase was also similar between the robotic (154 (92-245)) and the open (132 (72-166)) groups. There was no mortality in either group. Conclusion: Robotic biliary revision is a safe alternative to traditional open surgery for refractive biliary strictures after liver transplantation.

An unusual presentation and management of incarcerated Richter’s type of Spigelian hernia: a rare case report and review of literature

Spigelian hernias (SH) are one of the rare forms of ventral abdominal hernias which constitutes about 1-2%. SH occurs through the defect in the anterior abdominal wall adjacent to the semilunar line which occurs in the lower abdomen where the posterior sheath is deficient. The usual presentation of SH is a painful mass in mid abdomen above anterior superior iliac spine (ASIS). The diagnosis is made by means of ultrasound and computed tomography (CT). We report 69 years old female who is a known case of Parkinson’s disease and on medication presented with 2 days of sudden-onset right iliac fossa (RIF) associated with intermittent nausea, vomiting and also abdominal distension. O/E: Abdomen soft, tenderness in RIF with swelling above the line of ASIS. With the diagnosis of lateral abdominal wall hernia we took a CT scan that shows obstructed SH. Immediately she underwent surgery, intra-operative picture shows intraparietal hernia with Richter’s type and viable bowel. Abdominal wall is very weak and flimsy with no proper differentiation between the layers. Preperitoneal mesh repair was performed. The post-operative (post op) period was uneventful. Till now there was only 6 type of Richter’s SH reported. In this article we discuss a brief knowledge of SH and the management part of SH. We hope that this article will benefit among the surgeons in treating with SH.

Left Mid Abdomen: An Initial Trocar Entry Site (for complex surgical cases)

Study Objective To demonstrate technique and safety of initial trocar entry into the left mid abdominal wall. Design Video. Setting Small Tertiary Academic University Hospital Center. Patients or Participants N/A Interventions Outline anatomical point on abdomen. Show with video how entry can be accomplished in safe manner. Measurements and Main Results N/A Conclusion Left mid abdomen can be utilized as an initial site for trocar entry with the proper knowledge and setup.

The Great Escape: The Surprising Finding in a Case of Acute Vomiting

Question: A 23-month-old girl with no chronic medical conditions presented to the emergency department for 4 days of nonbloody nonbilious emesis. The patient had decreased oral intake, decreased urine and stool output, and fatigue. The patient did not experience any fevers, upper respiratory illness symptoms, difficulty breathing, hematemesis, hematochezia, melena, or diarrhea. The physical examination did not reveal any peritoneal signs. An abdominal radiograph revealed multiple radiopaque beaded foreign bodies in a circular configuration located in the mid abdomen (Figure A).

S1801 Got It From My Mama: Case Report of Mesenteric Adenocarcinoma

INTRODUCTION: Mesenteric tumors are uncommon. They arise from peritoneum, lymphatic, fat, and connective tissue. Generally, consist of nonneoplastic or neoplastic tumors. We report a case of an unusual mesenteric adenocarcinoma. CASE DESCRIPTION/METHODS: A 83-year-old female presented for a routine surveillance colonoscopy. She had undergone right hemicolectomy (2015) for stage II colon cancer (T3N0M0). She had a strong family history of cancer: colon and pancreatic cancer ( mother), rectal cancer (brother) and lung cancer (sister). She had previously undergone TAH BSO (1999). She presented with vague epigastric discomfort and post prandial pain but had no nausea, vomiting or weight loss. CT scan revealed a focal mass with rim enhancement near the inferior aspect of the pancreatic body measuring 4 cm × 3.7 cm and wall thickening of the gastric antrum. On EGD 4 nonbleeding antral ulcers were seen. EUS demonstrated a 5.2 × 3.6 cm irregular mass near the pancreatic neck, heterogenous and cystic but separate from the pancreas. FNA positive for adenocarcinoma. On PET scan a centrally necrotic neoplasm of the right mid abdomen was identified. CEA and CA19-9 were not elevated, HGB and LFTs were normal. At the time of this abstract the patient was receiving neoadjuvant chemotherapy. DISCUSSION: Mesenteric tumors consist of peritoneal cysts, enteric cysts, mesenteric mesotheliomas, mesenteric lipodystrophy, lymphangiomas, desmoid tumors (associated with FAP & Gardner syndrome), mesenteric lymphoma, mesenteric Carcinoid tumors & metastatic tumors. Medical evaluation consists of clinical examination, imagery and histopathology. Therapeutic management vary from observation, medical therapy to surgery: (Dufray et al. 239).This case underscores the importance of a thorough post-operative surveillance in patients with colo-rectal cancer. Implementation of postoperative surveillance guideline recommendations will potentially aide with early detection of metachronous colorectal lesions and other primary neoplasm in other organ systems.

S2783 Ileocolonic Fistula Due to Diffuse Large B-Cell Lymphoma: Unusual Presentation of a Rare Disease

INTRODUCTION: Malignant fistula is a rare complication of primary gastrointestinal lymphomas (PGIL) such as primary aggressive diffuse B cell lymphoma (DLBCL) of the ileum. These fistulas are frequently misdiagnosed. Currently there is no standardized treatment approach. We present a case of DLBCL complicated with a malignant ileocolonic fistula in a 55-year-old male with favorable outcome after surgery and chemotherapy. CASE DESCRIPTION/METHODS: A 55-year-old male presented with 3 months of watery non-bloody diarrhea and 3 weeks of abdominal pain associated with nausea. He denied any vomiting, anorexia, weight loss, fever or chills. Labs revealed a CRP of 15.3 mg/dl and leukocytosis of 14.3 k/ul. Non-contrast CT of abdomen and pelvis showed a focal aneurysmal dilation of a small bowel loop in the mid lower abdomen with associated lymphadenopathy and fluid filled sigmoid colon consistent with a small bowel tumor with an enterocolonic fistula (Image). This was confirmed on colonoscopy which showed a large sigmoid fistula 30 cm from the anal verge communicating with the midgut lumen through a medium sized ulcerated mass (image). He underwent en bloc excision. Both colonoscopy and surgical pathology confirmed high grade primary DLBCL, germinal center like originating from the ileum. Post-operative PET/CT scan showed persistent neoplastic process in the left para aortic lymph nodes. He received 6 cycles of R-COEP with complete resolution of symptoms. Follow up PET/CT scan showed no residual disease and was declared to be in complete remission. DISCUSSION: Ileocolonic fistulas due to PGIL is a rare occurrence with only less than 10 cases reports that we were able to find in literature. These fistulas are commonly misdiagnosed due to unspecific clinical presentation. Currently, there is no consensus on the standard treatment approach. We acknowledge the approach of en bloc surgical resection with adjuvant chemotherapy because of the excellent clinical outcomes observed with our patient, but admit that more data is required to demonstrate the most effective approach to treat PGIL.Figure 1.: Unenhanced cross section CT scan of the abdomen showing an ileocolonic fistula with aneurysmal dilation of the small bowel.Figure 2.: Endoscopic picture showing the fistula at 20cm from the anal verge(left) and a small bowel fistulizing mass(right).Figure 3.: H&E (left) and BCL6 (right) stained histology slides showing Malignant high grade DLBCL cells infiltrating the small bowel.

S2862 Bowel Within the Bowel; A Case of Metastatic Melanoma Presenting as Small Bowel Intussusception

INTRODUCTION: Melanoma is notorious for metastasizing to almost any part of the body. Metastasis to the gastrointestinal tract is most commonly diagnosed on autopsy. A clinical diagnosis is rare and occurs in approximately 2% of cases. We present a rare case of metastatic melanoma to the small bowel that presented as melena and ultimately caused small bowel intussusception. CASE DESCRIPTION/METHODS: 84-year-old male was admitted to the hospital with one-week history of melena and worsening abdominal pain. Past medical history was significant for stage IIB metastatic melanoma. Melanoma was first diagnosed on bottom of right foot 10 years prior to admission and was treated with surgical excision and adjuvant pegylated interferon. Patient had recurrence of melanoma on his back 1 year prior to presentation and underwent surgical excision and was treated with nivolumab. Physical examination revealed two new dermal nodules on the left chest. Laboratory investigations showed a decrease in hemoglobin from 11.5 g/dl three months prior to 9.5 g/dl. Esophagogastroduodenoscopy (EGD) was remarkable for a large, purplish, smooth mass in the third portion of the duodenum which was biopsied. Colonoscopy was unremarkable. Histologic examination revealed neoplastic cells positive for MART-1 and negative for CD3 and CD20. Immunohistochemical staining demonstrated that the malignant cells were positive for S100 which confirmed the diagnosis of metastatic melanoma. The patient was discharged however again presented to the Emergency Department with severe abdominal pain. Computed tomography with contrast showed small bowel intussusception within the left mid abdomen with dilated loops of small bowel proximally and collapsed loops of small bowel distally. Patient was taken for an emergent laparoscopic small bowel resection due to concern of ischemia. He was found to have multiple intra-abdominal lesions studding the small bowel and mesentery. Further metastatic workup revealed lesions in the lungs and the brain suggestive of advanced disease. Decision was made to proceed with palliative ipilimumab chemotherapy and radiation. DISCUSSION: Small bowel tumors are rare, accounting for only 3–6% of all GI tumors. Small bowel melanomas can be primary or metastatic lesions. Clinical presentation of GI metastases includes abdominal pain, overt bleeding, anemia, intestinal obstruction or rarely intussusception. Surgery may not be curative, however is the treatment of choice as it is effective in palliating symptoms and may prolong survival.Figure 1Figure 2

Chondrosarcoma pelvis, beyond the boundaries.

Objectives: The objective of our study to find the outcome of extensive chondrosarcoma pelvis after surgery. Study Design: Case Series study. Setting: Department of Orthopaedic Surgery Dow University of Health Sciences / Civil Hospital Karachi. Period: From April 2014 to December 2018. Material &amp; Methods: Seven patients with Chondrosarcoma pelvis included in this study. Results: All Seven patients were male. 2 patient age was in 20’s, three in 40’s and two in 60’s with median age of 44. Clinically presentation of patients was variable. One patient present with groin lump, one with pain and swelling lower abdomen, three with hip pain, one patient with severe gluteal pain and lump, one with massive lump extending from the mid abdomen to groin and urine retention and constipation. Five patients have left pelvis involved and two have right side. Two patients have pubic bone and ischium (Level III) involved, two have ilium (Level I) and three have ilium, acetabulum and pubis (Level I, II, III). Two patients with have preoperatively sciatic nerve palsy. Two patients have medical comorbid. One was asthmatic and one had psychiatric illness. No patient had metastasis at presentation. Pubis and ischium with tumor resected in two cases, partial ilium resection in one case, one complete P1 resection with sciatic nerve, one patient have internal hemipelvectomy and one patient had internal hemipelvectomy that bone recycled in liquid nitrogen and pelvis re-implanted and fixed with recon plates and hip joint reconstructed with total hip replacement. One patient had external hemipelvectomy due to pus at tumor site. Total duration of surgery in patient having thirteen hours, and remaining have 3 to 5 hours. Blood loss during these surgeries was in between 1000 to 1200 ml. Three patients have wound infection, one patient had L5 nerve root injury. Patient with external hemipelvectomy develop wound dehiscence and uro-cutaneous fistula. Two patients died, one with recycled bone after 15 months due cardiac problem and 2nd due to disease related complications within 3 months of surgery. Conclusion: Pelvic chondrosarcoma must be operated by the team of surgeons including orthopaedic surgeon, urologist and general surgeon because of the tumor presents with massive lumps due to unrestricted compartment and can involve the important pelvic organ. With team any complication can be prevented and treated immediately.

Can MDCT Measures of Upper Airway Dimensions and Central Obesity Indices Predict the Severity of Obstructive Sleep Apnea (OSA)?

Abstract Background: Comparative evaluation of the CT measures of upper air way, tongue adiposity and central obesity in a group of obstructive sleep apnea (OSA) patients and in a control group, and their potential role in grading of OSA severity. Aim of Study: The objective of the present study was to comparatively evaluate the different the upper air way, tongue adiposity and central obesity measures by CT scan in patients with obstructive sleep apnea syndrome (OSA) and in a control group, and their potential role in grading of OSA severity. Material and Methods: This prospective case control study was carried out on 17 OSA patients diagnosed by PSG and 16 control subjects. Non contrast MDCT scan of the upper airway and mid abdomen was performed on Philips 128 detector scanner, 1mm slice collimation during quite breathing. Axial and Sagittal reformatted images were assessed. Man-dibular plane hyoid distance (MPH), upper airway length (UAL), minimum cross-sectional area (MCA), transverse and antero-posterior diameters of the airway (TDA, APD), length and thickness of uvula and soft palate (LUV,TUV), tongue area and tongue base density (TA, TD) were measured. Image J program was used for quantification of neck and visceral adipose tissue (NAT, VAT). Results: Statistically significant difference was found in most CT measures between the OSA and control groups, the highest significant values were found with MCA, TDA, TUV and TA (p < 0.005). MCA and TA had the best diagnostic performance for OSA diagnosis. Statistically significant difference was found in MPH, UAL, MCA, TDA, TA, TD and NAT between the severe OSA and mild/moderate grades, The highest significant values was found with UAL and MCA (p=0.001, 0.002). For identifying severe OSA MCA, TDA and TA offered high diagnostic performances. Binary logistic regression found that TA and MPH were the significant predictors for severe OSA with overall % predicted=88.2%. Conclusion: Our results indicate that CT offers added value in OSA diagnosis and prediction of severity, multiple CT measures varied significantly between OSA and control group as well as between different OSA grades.

SUN-902 Bradycardia as a Presentation of Malignant Pheochromocytoma

IntroductionPheochromocytoma usually presents with tachycardia, hypertension and other symptoms related to catecholamine release. Bradycardia has been reported in up to 10% of patients and is due to an unusual reflex to cathecolamine surge.Case Report:57-year-old morbidly obese female with a history of COPD, hypertension, paroxysmal bradycardia, and urinary incontinence was referred to endocrinology clinic after an adrenal mass was found incidentally as part of a work-up for microscopic hematuria and urinary incontinence. CT abdomen showed unilateral 3.3 x 3.9 cm left lobular adrenal mass. Family history was negative for malignancies or pheochomocytoma. Patient denied substance abuse or ethanol use. Her medications include amlodipine, hydrochlorothiazide and albuterol. Physical exam was remarkable for a BMI of 51.6 and bradycardia of 50 bpm and well controlled blood pressure. On further review of her history, patient had prior visits to outpatient and emergency department for chronic headaches, insomnia, palpitations and sweating. Patient had a previous admission 13 years prior for chest pain and hypertensive urgency associated with headache and junctional bradycardia.Laboratory workup was significant for serum metanephrine levels of 749 pg/ml (normal <42), serum normetanephrine 185 pg/ml(normal <145), serum chromogranin A 130 ng/L(normal <39) and 24hr urine metanephrine of 1340 ug/24hr (normal <96) and urine normetanephrine of 357 ug/24hr (normal <80). Previous ECG showed sinus bradycardia. Echo-cardiogram revealed normal ejection fraction with left atrial enlargement.MIBG showed large focal area of intense radio-tracer accumulation in left mid abdomen and small focal lesions in the liver. Diagnosis of malignant pheochromocytoma was made and patient was referred to another institution for further management.Conclusion:Malignant pheochromocytoma is a rare neuroendocrine tumor that usually presents with tachycardia and hypertension. 10% of patients with malignant pheochromocytoma can debut with bradycardia due to sinus arrest. Although malignant and benign pheochromocytoma share the same clinical and histological features, the presence of metastasis is the main clue to differentiate them. Surgery remains the main treatment option even if complete debulking cannot be achieved. Nuclear radiation therapy or chemotherapy are two other therapeutic options that can be considered alone or in combination with surgery depending on the patients’ comorbidities. Lifetime surveillance is recommended as recurrence can occur up to 40 years after original resection. References-Chen H, Sippel RS, O’Dorisio MS, Vinik AI, Lloyd RV, Pacak K. The North American Neuroendocrine Tumor Society consensus guideline for the diagnosis and management of neuroendocrine tumors: pheochromocytoma, paraganglioma, and medullary thyroid cancer. Pancreas. 2010 Aug;39(6):775-83.

Aortic anastomotic pseudoaneurysm repaired with iliac branched endoprosthesis

A 75-year-old man undergoing surveillance imaging for a known pseudoaneurysm of the aortic anastomosis of an aortobifemoral bypass graft placed 20 years prior for occlusive disease was found to have increase in pseudoaneurysm size to 6 cm (A/Cover). The patient has a history of chronic obstructive pulmonary disease and non-small cell lung cancer with right upper lobectomy. He is of very thin habitus, and a pulsatile mass was visible in his left mid abdomen. Previously, the patient had undergone multiple cutdowns to the right and left groin for graft thrombectomies, pseudoaneurysm repair, as well as distal bypass and revision of the distal bypass with the last intervention 5 years previously.

Maffucci syndrome with multiple soft-tissue hemangiomas: A rare case report

Maffucci syndrome, a congenital mesodermal dysplasia, characterized by multiple enchondromas and hemangiomas was first described in 1881, and 200 cases have been reported in the literature since then. Here, we report the case of a 30-year-old male who presented with multiple soft, compressible swellings present on the back and right feet for 15 years and swelling of the right knee joint with difficulty in walking for 2 years. Roentgenogram of the right foot and hand showed multiple, small radiolucent (osteolytic lesions) areas at 1st metatarsal, distal phalanges, cuneiforms, talus bones, and 1st metacarpal bone suggestive of enchondromas. Doppler study showed venous malformation. Computed tomography (CT) scan of the right lower limb extending up to mid abdomen was suggestive of Maffucci syndrome with soft-tissue hemangioma and intraosseous enchondromas in the tibia and femur. This case is being reported for its rarity. These patients have a possibility of malignant transformation in about 30% of cases thus requiring early detection and management if required.

Coronal STIR sequence, a simple adjustment to routine MRI protocol for extra-spinal sciatica and sciatica-like symptoms

BackgroundThe value of adding coronal STIR images to MR imaging of sciatica aiming to detect extra-spinal abnormalities.ResultsAdditional coronal STIR images detected extra-spinal abnormalities in 20% of the patients, thereby downgraded the normal studies from 21 to 13%. The extra-spinal abnormalities included bone abnormalities (36.4%), soft tissue abnormalities (4.5%), neurological abnormalities (2.3%), gynecological abnormalities (50%), and miscellaneous (6.8%). In 6.9% of patients, the extra-spinal abnormalities explained the patients’ pain and influenced their management. Extra-spinal causes of pain significantly correlated to positive trauma and neoplasm history, normal routine protocol images, and absent nerve root impingement. Extra-spinal abnormalities were more prevalent in age groups (20–39 years).ConclusionCoronal STIR images (field of view: mid abdomen to the lesser trochanters) identify extra-spinal abnormalities that maybe overlooked on routine MRI protocol. It is of additional value in young adults, trauma, neoplasm, and negative routine images.

Extensive Fatty Replacement of the Pancreas (Pancreatic Lipomatosis) in a Dog

A 12-year-old neutered female mixed-breed dog was referred for occasional vomiting that had increased progressively in frequency over the past 3 months. Palpation of the abdomen revealed a firm mass of unknown aetiology, located within the cranial to mid abdomen, while abdominal surgical exploration revealed a well-defined abdominal mass of pancreatic origin. The pancreatic mass caused lateral displacement of the duodenum as well as medial displacement of the pylorus, resulting in impairment of pyloric outflow. Further examination revealed a firm, poorly vascularized and coarsely lobulated structure. The histopathological findings were consistent with severe pancreatic lipomatosis and atrophy. Immunohistochemically, the remnant pancreatic cells were positive for cytokeratins AE1/AE3 and glucagon, and negative for insulin. Routine follow-up with the referring veterinarian showed no evidence of postoperative complications, but the dog continued to deteriorate further and died despite medical management. Pancreatic lipomatosis is a rare condition in small animal practice. The aetiology or predisposing factors have not been identified in animals.